The patient has the right to be informed of these rights, as evidenced in the patient's written acknowledgement or by documentation by staff in the medical record, that the patient has had an explanation of these rights.
- The patient has the right to considerate and respectful care in a safe setting.
- The patient has the right to personal privacy.
- The patient has the right to be free from mental and physical abuse, free from exploitation, and free from the use of restraints unless authorized by the physician for a limited amount of time to protect the patient or others from injury. Drugs and other medications shall not be used for discipline of patient or convenience of the facility staff.
- The patient has the right to expect personnel who care for you to be friendly, considerate, respectful and qualified through education and experience, as well as perform the services for which they are responsible with the highest quality of service.
- The patient has the right to complete information about diagnoses, possible treatment, and prqgnosis in a manner that is understandable. When it is not medically advisable to give such information to the patient, the information should be made available to the patient's designated representative who shall exercise the patient's rights.
- The patient has the right to receive complete information from the surgeon regarding proposed treatment or procedure, necessary to give informed consent or to refuse this course of treatment. This information shall include a description of the procedure or treatment, the medically significant risks involved, alternate course of treatment or non-treatment and to know the name of the person· responsible for the procedure or treatment. The patient also has the right to request another physician other than the one assigned.
- The patient has the right to refuse treatment to the extent permitted by law and be informed of the medical consequences of that action. The patient accepts the responsibilities should treatment be refused or if the instructions given by the physician or facility are not followed.
- The patient has the right to expect that all communications and recordings pertaining to care, .including financial records, be treated as confidential and not released without written authorization by the patient, except in the case of transfer to another health care facility or as required by law or a third-party payment plan.
- The patient has the right to have full access to your medical record.
- The patient has the right to have an initial assessment and regular assessment of pain.
- The patient has the right to know about facility fees and payment methods. The patient has the right to have an explanation of the bill, regardless of the source of payment.
- The patient has the right to express grievances, complaints or suggestions at any time. If a patient has a grievance with the facility, he may speak immediately with the Administrator or a formal written grievance may be completed Complaints may be made to:
Division of Health Facilities Evaluation & Licensing NJ Department of Health
P.O. Box367 Trenton, NJ 08625-0367
State of New Jersey -Office of the Ombudsman for the Institutionalized Elderly
P.O. Box808 Trenton, NJ 08625-0808
- The patient has the responsibility to provide accurate and complete information concerning his/her present complaints, past illnesses, hospitalizations, medications (including over the counter products and dietary supplements), allergies and sensitivities and other matters relating to his/her health.
- The patient and family are responsible for asking questions when they do not understand what they have been told about the patient's care or what they are expected to do.
- The patient is responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician's orders.
- The patient is responsible for keeping appointments and for notifying the facility or physician when he/she is unable to do so.
- The patient and/or family member/patient representative is responsible for disposition of the patient valuables.
- Provide a responsible adult to transport him/her home from the facility and remain with him/her for a period of time designated by his/her physician unless exempted from that requirement by the attending physician.
- In the case of pediatric patients, a parent or guardian is to remain in the facility for the duration of the patient's stay in the facility.
- The patient is responsible for his/her actions should he/she refuse treatment or not follow his/her physician's orders.
- The patient is responsible for assuring that the financial obligations of his/her care are fulfilled as promptly as possible.
- The patient is responsible to infomn the facility whether the patient has a living will, medical power of attorney or other directive that could affect his/her care.
- The patient is responsible for being respectful of all of the health care providers and staff, as well as other patients.
- Parents/family shall have the responsibility for:
Continuing their parenting role to the extent of their ability
- Being available to participate in decision-making and providing staff with knowledge of parents/family whereabouts
- The family consists of those individuals responsible for physical and emotional care of the child on a continuous basis, regardless of whether they are related
DISCLOSURE OF PHYSICIAN OWNERSHIP
This disclosure is made in accordance with the Medicare Conditions for Coverage of Ambulatory Surgery Centers certification requirements. 416.50(b) Standard: Notice of rights: The Ambulatory Surgery Center (ASC) must also disclose, where applicable, physician financial interests or ownership in the ASC facility. Disclosure of information must be in writing. The intent of this disclosure requirements is to assist the patient in making an informed decision about his or her care by making the patient, or the patient's representative, aware when physicians who refer their patients to the ASC for procedures, or physicians who perform procedures in an ASC also have an ownership or financial interest in the ASC. The following Medical Staff members have ownership or financial interest in our facility:
Eric Bonifield, MD
- Robert Chapdelaine, MD
- Jacob Fassman, DPM
- Nauveed Iqbal, MD
- Per Montero Pearson, MD
- David Pernelli, MD
- Armando Russo, MD
- Seth Silver, MD
- Harris Slavick, MD
- Woo Song, MD
- Catherine Wisda, MD
All Patients have the right to participate in their own health care decisions and to make advance directives or to execute powers of attorney. These documents authorize others to make decisions on the patient's behalf based on the patient's expressed wishes when the patient is unable to make decisions or unable to communicate decisions. This surgery center respects and upholds those rights.
However, unlike in an acute care hospital setting, The ASC does not routinely perform high risk procedures. Procedures performed in this facility are considered to be of minimal risk. Of course, no surgery is without risk. You will discuss the specifics of your procedure with your surgeon who can answer your questions as to: risks, your expected recovery and care after your surgery.
Therefore, it is our policy, regardless of the contents of any advance directive or instructions from a health care surrogate or attorney in fact, that if an adverse event occurs during your treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to a hospital for further evaluation. At the hospital, further treatment or withdrawal of treatment measures already begun, will be ordered in accordance with your wishes, advance directive or health care power of attorney.
(If a patient should provide his/her advance directive, a copy will be placed on the patient's medical record and transferred with the patient should a hospital transfer be ordered by his/her physician). For more information on Advance Directives, please visit the following website:www.lsnjlaw.org.
NOTICE OF HEALTH INFORMATION PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At Ambulatory Care Center, we are committed to treating and using your protected health information responsibly. Under federal and state law, your patient health information is protected and confidential. This Notice of Health Information Practices describes the personal health information we collect and how and when we use or disclose that information. It also describes your rights and our responsibilities as they relate to your protected health information.
Understanding your Health Record/lnformation
Each time you visit Ambulatory Care Center, a record of your visit is made. Typically, this record contains your demographic information, medical history, procedure notes, test results, diagnoses, prescription copies, discharge instructions and signed consents. This information, often referred to as your health or medical record, serves as a:
- Basis for planning your care and treatment.
- Means for nursing to contact you for follow-up.
- Legal document describing the care you received, and consents you have given.
- Means by which a third-party payer can verify who you are, and that services billed were actually provided.
- Source of information for public health officials charged with improving the health of this state and the nation.
- Means by which a pathology lab can process and bill for biopsy samples.
- Means by which we can assess and improve the care we render at our facility, and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to ensure its accuracy, beHer understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Uses and Disclosures of your Health Information
As described above, your health information is used for a number of different and important purposes. In some circumstances, we may use or disclose your health information without seeking your permission. The following are some examples of ways your information may be used or disclosed:
Treatment:We will use and disclose your health information for medical treatment purposes. For example, your doctors and nurses will update your medical record and use it to determine the best course of care. Additionally, your information may be disclosed to other health care providers involved in your treatment, or to the pharmacist who will be filling your prescriptions.
Payment: We will use and disclose your health information for payment purposes. For example, we will use your health information to prepare and submit bills and we may need to submit information to your insurance company to obtain authorization prior to providing certain types of treatment.
Health Care Operations: We will use and disclose your health information to conduct our standard internal operations. For example, we may use or disclose your health information to conduct quality assessment and improvement activities and for business management and other general administrative activities.
Special Uses: We may use your information to contact you with appointment reminders or to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Other Uses or Disclosures: We may use or disclose your health information for the following purposes without your consent and, in some cases, we may be required to do so:
State-Specific Reguirements: New Jersey has separate privacy laws that apply additional legal requirements. We will follow the New Jersey law requirements.
- Required by Law: We may be required to disclose your health information to certain legal authorities if it relates to suspected crimes, abuse, neglect, or similar injuries or events.
- Public Health Activities: We may be required to disclose your health information to public health officials for purposes of collecting vital statistics, information related to disease control, federal regulation of food and drug quality and safety, etc.
- Health Oversight We may be required to disclose your health information to certain regulatory authorities for purposes of oversight the health care system, government programs, and regulatory compliance investigations or audits.
- Judicial and Proceedings: We may disclose your health information in response to a lawful subpoena, discovery request, or court order.
- Deaths: We may disclose information to coroners, medical examiners, funeral directors, or organ donation agencies.
- Serious Threat to Health or Safety: We may disclose your health information if necessary to prevent or lessen a serious threat to the health or safety of a person or the public.
Military and Special Government Forces: If you are a member of the armed forces, we may disclose your information to appropriate military command authorities at their request. Additionally, we may disclose information to a correctional institution or law enforcement official as required for the care, health and safety of inmates and/or employees of the correctional institution.
- Workers' Compensation: We may disclose information in compliance with workers' compensation laws or similar programs.
Other Uses and Disclosures
There are special regulations on certain health information including psychotherapy, substance abuse, mental health, genetic testing, reproductive health, and HIV/AIDS. As the surgery center does not generally treat such conditions, our records in these areas will be incidental to other health records which we may receive from other providers. Nevertheless, we will not disclose these types of records without specific written authorization. In any other situations not identified in this notice, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you decide to aulhorize the use or disclosure of your health information, you may later revoke such authorization, as provided by 45 CFR § 164.508(b)(5), to prevent the future use or disclosure of your health information in this way.
Your Health Information Rights
Although your health record is the physical property of Ambulatory Care Center, the information belongs to you. You have the right to:
Request a restriction on certain uses and disclosures of your health information for treatment, payment, health care operations, or other permitted purposes, as provided by 45 § CFR 164.522(a). Please note, however, that we are not required to agree to the requested restriction, except for a request to restrict disclosures to a health plan if the disclosure is for payment or health care operations purposes and pertains solely to a health care item or service for which you (or someone on your behalf) have paid your health care provider out of pocket in full.
- Receive confidential communications of your health information, as provided by 45 § CFR 164.522(b).
- Inspect and copy your health record as provided by 45 CFR § 164.524.
Amend your health record as provided in 45 CFR § 164.526.
- Receive an accounting of disclosures oi your health information as provided in 45 CFR § 164.528.
- Obtain a paper copy of this health notice of information practices upon request.
Ambulatory Care Center is required by law to:
- Maintain the privacy of your health information.
- Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
- Abide by the terms of the notice of health information practices currently in effect.
- Notify you of any breach of your health information that we are required by law to report to you.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide a revised notice to you at your next visit should you request one.
For More Information or to Report a Problem:
If you have questions and would like additional information regarding our privacy practices, you may contact the Administrator, Bridget Panco, at 856.507.0800. If you believe your privacy right has been violated, you can file a complaint as above with the Office for Civil Rights, U.S. Department of Health and Human Services.
You will not be penalized in any way for filing a complaint. The address for the OCR is listed below:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201