Notice of Patient Rights and Responsibilities

This document is meant to inform our patients of their rights and responsibilities while undergoing medical care. To the extent permitted by law, patient rights may be delineated on behalf of the patient to his or her guardian, next of kin, or legally authorized responsible person if the patient: a) has been adjudicated incompetent in accordance with the law, b) is found to be medically incapable of understanding the proposed treatment or procedure, c) is unable to communicate his or her wishes regarding treatment, or d) is a minor. If there are any questions regarding the contents of this notice, please notify any staff member.

Patient Rights

  1. Access to Care. You will be provided with impartial access to treatment and services within this practice’s capacity, availability, applicable laws and regulations. This is regardless of race, creed, sex, national origin, religion, disability/handicap, or source of payment for care/services.
  2. Respect and Dignity. You have the right to considerate, respectful care/services at all times and under all circumstances. This includes recognition of psychosocial, spiritual, and cultural variables that may influence the perception of your illness.
  3. Privacy and Confidentiality. You have the right, within the law, to personal and informational privacy. This includes the right to:
    • Be interviewed and examined in surroundings that assure reasonable privacy.
    • Have a person of your own sex present during physical examination or treatment.
    • Not remain disrobed any longer than is required for accomplishing treatment/services.
    • Request transfer to another treatment room if a visitor is unreasonably disturbing.
    • Expect that any discussion or consultation regarding care will be conducted discreetly.
    • Expect all written communications pertaining to care will be treated as confidential.
    • Expect medical records to be read only by individuals directly involved in care, quality assurance activities, or processing of insurance claims. No other persons will have access without your written authorization.
  4. Personal Safety. You have the right to expect reasonable safety insofar as the office practices and the environment is concerned.
  5. Identity. You have the right to know the identity and professional status of any person providing services and which physician or other practitioner is primarily responsible for your care.
  6. Information. You have the right to obtain complete and current information concerning diagnosis (to the degree known), treatment, and any known prognosis. This information should be communicated in terms that you understand.
  7. Communication. If you do not speak or understand the predominant language of the community, you should have access to an interpreter. This is particularly true when language barriers are a continuing problem.
  8. Consent. You have the right to information that enables you, in collaboration with the physician, to make treatment decisions.
    • Consent discussions will include explanation of the condition, risks and benefits of treatment, as well as consequences of no treatment.
    • You will not be subjected to any procedure without providing voluntary, written consent.
    • You will be informed if the practice proposes to engage in research or experimental projects affecting its care or services. If it is your decision not to take part, you will continue to receive the most effective care the practice otherwise provides.
  9. Consultation. You have the right to accept or refuse medical care to the extent permitted by law. However, if refusing treatment prevents the practice from providing appropriate care in accordance with ethical and professional standards, your relationship with this practice may be terminated upon reasonable notice.
  10. Charges. Regardless of the source of payment for care provided, you have the right to request and receive itemized and detailed explanations of any billed services.
  11. Rules and Regulations. You will be informed of practice rules and regulations concerning your conduct as a patient at this facility. You are further entitled to information about the initiation, review, and resolution of patient complaints.
  12. Commitment to Care. I understand that in order to have an effective doctor/patient relationship, it is my responsibility to be compliant with the physician’s office policies. I understand that I may terminate this relationship at any time and request my records and to transfer my care to another urologist. I also understand that my physician may terminate the doctor/patient relationship at any time giving a 30 day notice.

Patient Responsibilities

  1. Keep Us Accurately Informed. The responsibility to identify yourself, providing to the best of your knowledge, accurate and complete information about your medical history, present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health, including unexpected changes in your condition.
  2. Follow Your Treatment Plan. You are responsible for following the treatment plan recommended by the physician. This may include: following the instructions of health care personnel as they carry out the coordinated plan of care; implement the physician’s orders; and the enforcement of applicable practice rules and regulations, unless you have exercised your right to refuse treatment. You are responsible for asking questions when you do not understand medical information that you have received.
  3. Keep Your Appointments. You are responsible for keeping appointments and, when unable to do so for any reason, for notifying this practice within policies established.
  4. Take Responsibility for Noncompliance. You are responsible for your actions if you do not follow the physician’s instructions. If you cannot follow through with the prescribed treatment plan, you are responsible for informing the physician.
  5. Be Responsible for Your Financial Obligations. You are responsible for assuring that the financial obligations of health care services are fulfilled as promptly as possible, and for providing up-to-date insurance information.
  6. Be Considerate of Others. You are responsible for being considerate of the rights of other patients and personnel, and for assisting in the control of noise, smoking, and the number of visitors. You also are responsible for being respectful of practice property and property of other persons visiting the practice. If any disrespectful behavior, physical, emotional or verbal abuse occurs from the patient, or any client, the physician will be notified and may be grounds for the termination of patient/physician relationship.
  7. Be Responsible for Lifestyle Choices. Your health depends not just on the care provided at this facility but on the long-term decisions you make in daily life. You are responsible for recognizing the effects of these decisions on your health.
  8. Tobacco-Free Environment. To help ensure a safe and healthy environment for patients, guests, staff and others, the use of all tobacco products is prohibited in the clinic.
  9. Hand-Gun Policy. The Urology Team is a gun free zone as outlined by the Texas Penal Code. Weapons of any kind are restricted while in the clinic. This applies to patients, patient’s visitors/guests, and employees.
  10. Cellular Phones. You understand your responsibility to be prepared for your visit with your physician. Cellular phones are to be turned off when a patient is taken to the patient room in preparation to see the physician.

Commitment to Care: I understand that in order to have an effective physician/patient relationship, it is my responsibility to be compliant with the physician’s treatment recommendations, patient responsibilities and office policies. I understand that I may terminate the physician/patient relationship at any time and request that my medical records be transferred to another urologist. I also understand that my physician may terminate the physician/patient relationship at any time giving a thirty (30) days’ notice.

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