Rights & Responsibilities
You have RIGHTS…
…including the right to be informed of them in a way that you, your representative or surrogate can understand.
See the end of this notice for information on filing a complaint, a grievance, or a suggestion. You, your representative or surrogate have the right to do so verbally or in writing on the date of your scheduled treatment, as well as before or after that date.
You cannot be penalized in any way for exercising these rights.
You, your representative or surrogate have the right to know BEFORE the date of your procedure:
- Your expected appointment time
- How to get help if you have a problem or emergency when this surgery center is closed
- What kind of follow-up care you can reasonably expect
- If your doctor has any financial or ownership interest in this surgery center
- If your care provider is not covered by malpractice insurance
- What you will be billed for by this surgery center, regardless of who will be paying those charges
- The immediate and long-term financial effects of those charges
- This surgery center’s payment policies
If you are a Medicare beneficiary, you also have the right to:
- Receive the information and help you need to understand your Medicare options
- Assistance in exercising your Medicare rights and protections
The Medicare Beneficiary Ombudsman can also help you in resolving Medicare-related problems.
You, your representative or surrogate have the right to the following INFORMATION that you need in order to take part in making a good decision about your treatment:
- Your diagnosis (the disease or illness that is causing your problem)
- The doctor’s professional opinion on your condition • The prognosis (what generally happens to people who have the same diagnosis)
- What the doctor expects to happen in your case
- The treatment you will be receiving
- The risks and dangers of your treatment
If there is a good medical reason for not giving you this information, it will be given to someone that you choose or who has been given legal permission.
You, your representative or surrogate also have the right to:
- Know the name of the person who will be providing or assisting in your treatment
- Know the qualifications of that provider
- Change to another qualified provider, if available
- Expect that any advertising about the organization’s competence and abilities is accurate
- See your own medical record
- Be informed by your doctor or the doctor’s representative as to what kind of care you will need after discharge
You, your representative or surrogate have the right to expect that this outpatient surgery center will:
- Provide evaluation, services and/or referral appropriate to the urgency of your case and within the limitations of this surgery center
- Transfer you to another facility (such as a hospital) when required by your medical condition
You have PRIVACY rights related to your personal care.
We will keep all of the information in your medical record confidential, unless reporting is allowed or required by law.
There are a number of legal exceptions that allow or require us to use your information without asking for your permission. One example is the information your insurance company needs to process your claim. You can find a list of these exceptions in the “Notice of Privacy Practices” we have given you.
- You have a right to look at or copy your Protected Health Information (PHI).
If you need to look at or have a copy of your information, please ask for a request form or ask to speak with our privacy representative.
- You have the right to ask us to make changes to the written information we have about you.
If you believe that this written information is not correct, contact our privacy representative for a change request form.
- You have the right to ask us to limit how your medical information is used and who can get this information.
Do you need more information on your privacy rights? Details are available in the “Notice of Privacy Practices” that we have given you.
You have LEGAL rights that guarantee you will be:
- Safe from all types of abuse or harassment
- Treated with confidentiality, respect, dignity and consideration
- Able to refuse all or part of suggested treatment, including human experimental treatment
- Treated fairly, regardless of your race, color, religion, gender, sexual preference, disability, national origin, age, veteran’s status or source of payment (except for inability to pay)*
* These rights are guaranteed by Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services, conforming to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.
You have the right to submit an ADVANCE DIRECTIVE.
If you are too ill to speak for yourself, someone else will have to make decisions about your medical care for you. An“AdvanceDirective”isalegaldocumentthat makes it possible for you to communicate what kind of end-of-life care you want and to appoint someone you trust to make decisions for you. It will be less confusing for your family, friends, and the medical professionals
who take care of you if they have this information ahead of time.
- You have the legal right to choose someone to make decisions for you. The Center must follow the process and do everything it can to respect your wishes, within the limits of state law.
- If your state’s legal process determines that you are not able to make informed decisions or to exercise your rights yourself, you have the right to a state- appointed representative who can do these things for you.
You have the right to access the Advance Health Care Directive described in Caring Connections, a national program of the National Hospice and Palliative Care Organization (NHPCO). This program, aimed at improving care at the end of life, includes:
- Instructions for completing the Hawaii Advance Directive for Healthcare
- Learning options for end-of-life services and care
- How to make sure that your wishes are honored
- How to tell your family, friends, and healthcare providers about your decision
- How to participate in personal and community efforts to improve end-of-life care
- A copy of the Hawaii Durable Power of Attorney for Healthcare
This information is available on the Caring Connections website: www.caringinfo.org/files/public/ad/Hawaii.pdf
Upon request, you, your representative or surrogate, can obtain a copy of your state’s Advance Directive form at the Center.
You also have RESPONSIBILITIES.
As a patient you are responsible for providing CORRECT & COMPLETE INFORMATION on:
- Your present health
- Your past medical history
- The prescription and over-the-counter medicines you take, including vitamins and other dietary supplements
- Any allergies or sensitivities
- Anything else related to your health
You are responsible for:
- Following your doctor’s orders
- What happens if you do not follow your doctor’s orders
- What happens if you refuse treatment
- Telling us if you think you will not be able to follow through with the treatment ordered by your doctor
- Asking questions if you do not understand the information or instructions we give you
- Telling your doctor and this surgery center if you have a Living Will, a medical Power of Attorney, or any other directive that could affect your care
- Paying what you owe for services as soon as possible
You should respect the rights of other patients and the staff of this surgery center by:
- Helping us to control noise
- Not smoking
- Limiting the number of visitors
This surgery center has the right to refuse care to or dismiss patients who are disruptive, uncooperative, rude, or physically threatening to other patients or our staff.
You must provide a RESPONSIBLE PERSON who can:
- Drive you home when you are ready to leave this surgery center
- Stay with you for 24 hours, if ordered by your doctor
If your driver is disruptive, uncooperative, rude, or physically threatening, this surgery center has the right to refuse care to you or dismiss you from care. This includes drivers who are unable to provide safe transportation for any reason, including drug or alcohol intoxication.
If you have questions about your rights or want to file a complaint, please contact:
Clinical Director-Section 504 Coordinator
MIS Hawaii Surgery Center
1401 South Beretania St., Suite 600 Honolulu, HI 96814
You may also file a complaint by contacting:
State of Hawaii Department of Health, which is the agency responsible for investigating complaints about ambulatory surgical centers. You can file a complaint by phone (808) 586-4400 or by writing:
State of Hawaii Department of Health 1250 Punchbowl Street
Honolulu, HI 96813
You may provide your name, address, and phone number to the Department. You can also file a complaint without giving this information.
All complaints are confidential.
For Medicare beneficiaries: www.medicare.gov/ombudsman/resources.asp
National Hospice and Palliative Care Organization www.caringinfo.org/files/public/ad/ Hawaii.pdf
As a patient of MIS Hawaii Surgery Center, I understand that any co-pays, co-insurance, and/or deductibles are due prior to having my procedure. I understand that the following provider fees are NOT INCLUDED in the surgery center fee and will be billed separately:
- Physician (surgeon) fee
- Anesthesiology fee
- Laboratory services
For any questions or concerns, please call: 808-356-5682