New Patient Packet - Steward Health Care System · 2018-03-26 · NEW PATIENT INFORMATION FORM...

STATELIN

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New Patient Packet

1307 Trinity Boulevard Texarkana, AR 71854 Phone: 870-7SENIOR (773-6467) Fax: 870-216-0061

Julia Kim, MDFamily Practice - Geriatrician

Jerry Stringfellow, MDFamily Practice - Geriatrics

Amy Leigh Overton-McCoy, Ph.D., GNP-BCGeriatric Nurse Practitioner

Daniel Owens, RN, MSN, FNP-CFamily Nurse Practitioner






To Our New Patient:

On behalf of the entire sta� at the Wadley Senior Clinic, we would like to welcome you as a new patient. Our mission is to improve the quality of life by promoting healthy aging. We exclusively serve the healthcare needs of the older adult and o�er comprehensive and specialized care to help our patients maintain the maximum level of independence, health, and well being.

At your �rst appointment, we will gather a lot of information including demographic, medical history, and insurance information. Because of the lengthy appointment, it is important that you arrive 30 minutesprior to your scheduled time. This gives you time to get registered in and sign the appropriate paperwork. If you are late for your scheduled time, it may be necessary to reschedule your appointment.

Enclosed is a packet of information we will need you to �ll out and bring with you to your appointment. We will review your completed information packet and make copies of your insurance cards. We ask that you also bring all medications you are taking including over-the-counter medications, herbs, and vitamins with you to each appointment. The physician/nurse practitioner will review your medications at each visit.

The Wadley Senior Clinic is designed to provide an integrated, team approach to develop an individualized care plan just for you. We have a social worker on sta� to assist with access to community resources in an e�ort to help you maintain your independence as long as possible. Please let us know if she can be of assistance.

Because the Wadley Senior Clinic is an out-patient department of Wadley Regional Medical Center, the hospital bills a “facility fee” for each visit to the Clinic. You will also receive a bill from the physician. There is a hand-out in this packet that further explains the billing process. All Medicare plans as well as supplemental policies recognize these charges and will pay once deductibles are met. You will be responsible for deductibles and co-pays, depending on your plan coverage. Thank you for choosing the Wadley Senior Center and if you have any questions regarding our services or anything in this packet, feel free to call the o�ce at (870) 773-6467.

Sincerely,

Darren Crabbe, Clinic ManagerWadley Senior ClinicWadley Regional Medical Center

Senior Clinic New Patient Letter - Typeset 07-29-2013 Revised: 09-09-2014


Why does the Wadley Senior Clinic charge a facility fee?The Wadley Senior Clinic is an outpatient department of the hospital (Wadley Regional Medical Center). As an outpatient department of the hospital, we follow national guidelines and billing standards mandated by the Center for Medicare & Medicaid Services (CMS) for all patients and all visits – in the hospital setting and in hospital outpatient settings. CMS has de�ned facility fee insurance codes for outpatient “clinic visits” to reimburse hospitals for the level/intensity of the nursing services and hospital resources used in an outpatient clinic setting. The fees take into account the operating and overhead costs related to the building, service provided by our clinical and support sta�, supplies and equipment, as well as administrative costs related to support departments like Patient Financial Services.

Why is there a separate physician fee?Physicians who treat patients at hospital-owned facilities typically are not owners of the clinic. They use a special code when billing insurance companies and accept lower fees/insurance reimbursement than physicians who own their equipment, supplies, sta� and facilities.

Physicians who own their own facility and resources use di�erent insurance billing codes that include their facility/overhead costs into a single patient bill for an o�ce visit and are reimbursed at a higher rate by insurance providers.

Will my insurance cover the facility fee?Since facility fees are mandated by the Center for Medicare & Medicaid Services (CMS), they do partially cover the facility fee in their payment. If you have a Medicare secondary insurance, your secondary insurance will cover the remainder of the fee; however, if you do not have a secondary insurance you will be responsible for a portion of the facility fee not paid by Medicare or another primary payor.





Senior Clinic Facility Fee Sheet - Typeset 07-29-2013 Revised: 09-09-2014

NEW PATIENT INFORMATION FORM

Wadley Senior Clinic - New Patient Packet (Typeset 07-2013 Rev. 09-09-2014) Page 1 of 4

PHYSICIAN'S NAME

PATIENT'S FULL NAME:

# .TPA:SSERDDA PHONE NUMBER ( ) -EMAIL:

CITY STATE ZIP CODE WORK NUMBER ( ) -CELL NUMBER ( ) -

SEX: M F DATE OF BIRTH (MM/DD/YY)

PATIENT'S SOCIAL SECURITY # - -

PATIENT'S EMPLOYER:

EMPLOYER'S ADDRESS

OCCUPATION

IN CASE OF EMERGENCY CONTACT:

RELATIONSHIP PHONE NUMBER ( ) -

ADDRESS:

CITY/STATE: ZIP CODE:

INSURANCE INFORMATIONPRIMARY COVERAGE, CARRIER NAME:

SECONDARY COVERAGE, CARRIER NAME:

ETHNICITY AND RACE (please complete both sections)ETHNICITYPLEASE CHECK THE BOX BELOW THAT APPLIES TO YOU.

HISPANIC OR LATINO

NOT HISPANIC OR LATINO

RACEPLEASE SELECT THE RACIAL CATEGORY WITH WHICH YOU MOST CLOSELY IDENTIFY WITH:

AMERICAN INDIAN OR ALASKA NATIVE

ASIAN OR PACIFIC ISLANDER

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN

WHITE OR CAUCASIAN OTHER (PLEASE SPECIFY):

MARITAL STATUS:

Married Single

Widowed Divorced

ALT. PHONE NUMBER ( ) -

Wadley Senior Clinic - New Patient Packet (Typeset 07-2013 Rev. 09-09-2014 ) Page 2 of 4

DATE TODAY:WE STRIVE TO KEEP ALL INFORMATION IN CONFIDENCE AND WILL NOT RELEASE WITHOUT SIGNED CONSENT. It may be sent to consultants, if referred.

NAME: D.O.B. LAST FIRST M.I.

REASON FOR VISIT TODAY:

PAST MEDICAL HISTORY:MEDICAL CONDITIONS - Please check current or past illnesses:

High blood pressure High Cholesterol

Congestive Heart Failure Heart Attack

Asthma Kidney Problems

Diabetes Arthritis

Cancer - Type Other

COPD

Liver Disease

HEALTH MAINTENANCETest DateAnnual Wellness ExamPAP SmearMammogramColonoscopyStool CardsPSACholesterolBone Density

Eye ExamFlu vaccineShingles vaccineTetanus vaccinePneumonia vaccinePREVIOUS SURGERIES:

Cataracts Year: Breast Year:

Tonsillectomy Year: Hysterectomy Year:

Appendectomy Year: Pacemaker Year:

Prostate Surgery Year: Gall Bladder Year:

Orthopedic Surgery Year: Hemorrhoids Year:

Hernia Year: Heart Bypass Year:

FAMILY HISTORY: Check the box ( ) next to the condition that your family member has; then specify their relationship to you after the disease, using the abbreviations as follows:Mother (M), Father (F), Brother (B), Sister (S), Children (C)For example, if your Sister and Mother had breast cancer ( ) BREAST CANCER S.M.

Alcoholism Colon Cancer Kidney Disease Other

Anemia Diabetes Mental Illness Other

Asthma Glaucoma Osteoporosis

Arthritis Gout Prostate Cancer

Bleed easily Heart Disease Seizures

Breast Cancer High Blood Pressure Thyroid Disease

Echo

NEW PATIENT ADMISSION ASSESSMENT AND HISTORY

Other Year:

Wadley Senior Clinic - New Patient Packet (Typeset 07-2013 Rev.09-09-2014 ) Page 3 of 4

NAME: DOB: AGE:

Do you now or have you in the past 1 month had any problems related to the following systems? Circle Yes or No

Y NY NY NY NY N

Y NY NY N

Y NY NY N

Y NY NY NY N

ConstitutionalSymptomsFeverChillsHeadacheSweatsWeight LossOther

EyesBlurred visionDouble VisionPain

Other

AllergiesHay FeverRunny noseItchy eyes

Other

NeurologicalTremorsDizzy spellsNumbness/tinglingWeakness

Other

Y NY NY N

Y NY NY NY NY NY NY NY N

Y NY NY NY N

Y NY NY NY NY NY N

EndocrineExcessive thirstToo hot/coldWeight change

Other

Intestines, ColonTrouble swallowingNausea/vomitingIndigestion/heartburnAbdominal PainDiarrhea/constipationHemorrhoidsRectal bleedingBlood stoolOther

Heart and Blood VesselsChest painVaricose veinsRapid heart beatEdema / Swelling

Other

SkinSkin rashBoilsItchingMolesHair LossBruisingOther

Y NY NY NY N

Y NY NY NY NY N

Y NY NY NY NY NY N

Y NY NY NY NY N

Muscles and BonesJoint pain or stiffnessNeck painBack painJoint swelling

Other

Ear/Nose/Throat/MouthEar pain / hearing lossSore throatNasal congestionSinus pressure / painNose bleeds

Other

UrinationBurning with urinationUrgencyFrequencyBlood in urineEmptying bladder at nightVaginal discharge, pain, soresOther

RespiratoryWheezingCough - productive / dryShortness of breathSnoringBlood in sputum

Other

Y NY NY N

Y NY NY NY N

Y NY N

Y N

Y N

Blood/Lymph nodesEnlarged glands (lymphadenopathy)BruisingBleeding

Other

PsychologicSatisfied with your life?Depressed?Suicidal?Abused?

Other

Sexual/Menstrual HistoryChange in sex drive?

Sexual performance satisfactory? Sexual trauma?

Irregular bleeding? Other

N/AN/A

N/A

N/A

SOCIAL HISTORY:Tobacco Used Currently? Y / N # Packs per day: Used in the Past? Y / N When did you stop?: Alcohol Use? Y / N Beer: Y / N Oz (or glasses or cans per week average)? Caffeine Use? Y / N Cups per day: Drug use? Y / NExercise Regularly? Y / N Type: Times per week:

LIVING ARRANGEMENTS: Lives alone Lives with partner Lives with other Lives in apartment Lives in Care Facility

Assistive Devices: Cane Crutches Walker Dentures Partial Plate (Upper/Lower) Prosthetic Limb Hearing Aid Splint / Brace Glasses ContactsDo you currently have Home Health: Yes No Company:

NEW PATIENT ADMISSION ASSESSMENT AND HISTORY

MY MEDICATION / ALLERGY LIST

Wadley Senior Clinic - New Patient Packet (Typeset 07-2013 Rev.09-09-2014 ) Page 4 of 4

Name: Date of Birth:

Local Pharmacy name: Phone number:

Mail Order Pharmacy name: Phone number:

Write all prescriptions, over-the-counter medicines and supplements below.

Medication Name How much do I takeat each dose?

When and how do I take it?

Why do I take it?

Example: Naproxen 1 tablet, 250 mg 7AM and 7PM, with food Arthritis

Please list all known food and drug allergies and the reaction. NO KNOWN ALLERGIES

MEDICATION/FOOD REACTION

Katz Index of Independence in Activities of Daily Living

Activities Points (1 or 0)

Independence (1 Point)

NO supervision, direction or personal assistance

Dependence (0 Points)

WITH supervision, direction, personal assistance or total care

BATHING Points: __________

(1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity

(0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing

DRESSING Points: __________

(1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes.

(0 POINTS) Needs help with dressing self or needs to be completely dressed.

TOILETING Points: __________

(1 POINT) Goes to toilet, gets on and o�, arranges clothes, cleans genital area without help.

(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.

TRANSFERRING Points: __________

(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable

(0 POINTS)Needs help in moving from bed to chair or requires a complete transfer.

CONTINENCE Points: __________

(1 POINT) Exercises complete self control over urination and defecation.

(0 POINTS) Is partially or totally incontinent of bowel or bladder

FEEDING Points: __________

(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.

(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

Total Points: ________

Score of 6 = High, Patient is independent. Score of 0 = Low, patient is very dependent.

**Slightly adapted. Katz S., Down, TD, Cash, HR, et al. (1970) progress in the development of the index of ADL. Gerontologist 10:20-30. Copyright The Gerontological Society of America. Reproduced by permission of the publisher.

Senior Clinic Katz Index of Independence in Activities of Daily Living - Typeset 07-29-2013 - Revised 09-09-2014

Geriatric Depression Scale

1. Are you basically satis�ed with your life? NO yes 2. Have you dropped many of your activities and interests? YES no 3. Do you feel that your life is empty? YES no 4. Do you often get bored? YES no 5. Are you hopeful about the future? NO yes 6. Are you bothered by thoughts that you just cannot get out of YES no

your head? 7. Are you in good spirits most of the time? NO yes 8. Are you afraid that something bad is going to happen to you? YES no 9. Do you feel happy most of the time? NO yes 10. Do you often feel helpless? YES no 11. Do you often get restless and �dgety? YES no 12. Do you prefer to stay home at night, rather than go out and YES no

do new things? 13. Do you frequently worry about the future? YES no 14. Do you feel that you have more problems with memory than YES no

most? 15. Do you think it is wonderful to be alive now? NO yes 16. Do you often feel downhearted and blue? YES no 17. Do you feel pretty worthless the way you are now? YES no 18. Do you worry a lot about the past? YES no 19. Do you �nd life very exciting? NO yes 20. Is it hard for you to get started on new projects? YES no 21. Do you feel full of energy? NO yes 22. Do you feel that your situation is hopeless? YES no 23. Do you think that most people are better o� than you are? YES no 24. Do you frequently get upset over little things? YES no 25. Do you frequently feel like crying? YES no 26. Do you have trouble concentrating? YES no 27. Do you enjoy getting up in the morning? NO yes 28. Do you prefer to avoid social gatherings? YES no 29. Is it easy for you to make decisions? NO yes 30. Is your mind as clear as it used to be? NO yes

Normal 0-9 Mild Depression 10-19 30Severe Depression 20-30

www.psychologynet.org/geriatric.html

Senior Clinic Geriatric Depression Scale (Short Form) PAGE 2- Typeset 07-29-2013 Revised 09-09-2014

Effective Date: August 1, 2013

Joint Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

1. Purpose: Brim Healthcare of Texas, LLC d/b/a Wadley Regional Medical Center and its professional staff, employees, and volunteers and all of its affiliated entities (referred to collectively as Hospital) follow the privacy practices described in this Notice. The Hospital is required by law to maintain the privacy of your medical information. This Notice describes how we may use and disclose your medical information. Not every use and disclosure in a category will be listed. Your medical information is stored electronically and is subject to electronic disclosure.

.

2. Organized Health Care Arrangement. The Hospital and its medical staff participate together in an organized health care arrangement to provide health care to you at the Hospital. This Notice applies to physicians and other members of the Medical Staff who have agreed to abide by its terms concerning the services they perform at the Hospital. This Notice does not createan agency relationship, a joint venture, or any other legal relationship between those covered by this Notice. Under this arrangement, the Hospital may share your medical information as necessary for treatment, payment and health careoperations relating to the organized health care arrangement.

3. Uses and Disclosures for Treatment, Payment, and Health Care Operations. We will use and disclose your medical information for treatment, payment and health care operations. Treatment involves providing and coordinating your care. For example, we may disclose your information to a specialist to help diagnose or treat you. Payment involves uses and disclosures to assist in obtaining payment for our services. For example, we may disclose your information to health plans orother payors to determine whether you are enrolled with the payor or eligible for health benefits, submit claims for payment, and provide information to entities that help us submit bills and collect amounts owed. Health care operations involves our standard internal operations, such as quality assurance activities, peer review, arranging for legal services, providing appointment reminders and training.

4. Other Uses and Disclosures Not Requiring an Authorization. Your medical information may be used and disclosed as described below:

• Hospital directory to anyone who asks about you by name (may include your name, general condition, and your location in the Hospital).

• Religious affiliation and directory information to a hospital chaplain or member of the clergy.• Family members or close friends involved in your care or payment for your treatment.• A government disaster relief agency if you are involved in a disaster relief effort.• To inform you of treatment alternatives or benefits or services related to your health. If we receive anything of value for

making these communications, we will notify you of this fact, and you will have an opportunity to opt out of future communications.

• To contact you to raise funds for the Hospital, but information used and disclosed for fundraising will be limited to your name and other limited information permitted by law. You will have the opportunity to opt out of receiving fundraising communications.

• As required by law.• Public health activities, including disease prevention, injury or disability; reporting births and deaths; reporting child abuse

or neglect; reporting reactions to medications or product problems; notification of recalls; infectious disease control; notifying government authorities of suspected abuse, neglect or domestic violence (if you agree or as required by law).

• Health oversight activities (e.g., audits, inspections, investigations, and licensure activities).• Lawsuits and disputes (e.g., as required by a court or administrative order or in response to a subpoena or other legal

process).• Law enforcement (e.g., in response to legal process or as required or allowed by law).• Coroners, medical examiners, and funeral directors.• Organ and tissue donation organizations.• Certain research projects as approved by an Institutional Review Board or if certain conditions are met.• To prevent a serious threat to health or safety.• To military authorities if you are a member of the armed forces.• National security and intelligence activities.• Protection of the President or other authorized persons or foreign heads of state, or to conduct special investigations.• Inmates or others in custody to a correctional institution or law enforcement• Workers’ Compensation (in compliance with applicable laws).

Wadley Senior Clinic - Joint Notice of Privacy Practices (Typeset 07-2013 Rev.09-09-2014 ) Page 1 of 2

• To business associates (individuals or entities that perform functions on our behalf) (e.g., to install a new computer system) provided they agree to safeguard the information.

5. Substance Abuse Information. Alcohol and drug abuse information has special privacy protections. The Hospital will not disclose any information identifying an individual as being a substance abuse patient or provide any medical information relating to the patient’s substance abuse treatment unless (i) the patient consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel use the information for the purpose of conducting scientific research, management audits, financial audits, or program evaluation; or (v) it is necessary to report a crime of a threat to commit a crime, or to report abuse or neglect as required by law.

6. Your Authorization Is Required for Other Uses and Disclosures. Except as described above, we will not use or disclose your medical information unless you authorize (permit) the Hospital in writing to use or disclose your information. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your health information for marketing purposes or sell your health information, unless you have signed an authorization. You may revoke your authorization, and thereby stop any future uses and disclosures, by notifying us in writing.

7. Your Medical Information Rights. You have the following rights regarding your medical information, provided that you make a written request to invoke the right on the form provided by the Hospital:

• Right to request restriction. You may request limitations on how we use or disclose your medical information for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you have had a particular surgery). We are not required to agree to your request, except for requests to restrict disclosures to a health plan for purposes of payment or health care operations when you have paid in full out-of-pocket for the item or service covered by the request and when the disclosure is not required by law. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

• Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted and how payment will be handled.

• Right to inspect and copy. You have the right to look at and obtain a copy of your medical records, billing records, and other records used to make decisions about your care. We may charge you a fee for our postage and labor costs and supplies to create the copy. Under limited circumstances, your request may be denied and you may request review of the denial by another licensed health care professional chosen by the Hospital. The Hospital will comply with the outcome of the review. If your information is stored electronically and you request an electronic copy, we will provide it to you in a readable electronic form and format.

• Right to request amendment. If you believe that the medical information we have about you is incorrect or incomplete, you have the right to request that your records be amended. Under limited circumstances, the Hospital may deny your request for amendment. If denied, you will receive an explanation for the decision and information explaining your options.

• Right to accounting of disclosures. You may request a list of instances where we have disclosed your medical information for certain types of disclosures. The accounting will not include disclosures that we are not required to record, such as disclosures made pursuant to an authorization. The first accounting you request within a 12-month period is free, but we will charge a fee for any additional lists requested within the same 12-month period.

• Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may obtain an electronic copy of this Notice at our website, http://www.wadleyhealth.com

8. Other Obligations. The Hospital is required by law to provide you with this Notice. We will be governed by this Notice for as long as it is in effect and are also required to comply with any federal or state laws that impose stricter standards than those described in this Notice. The Hospital may change this Notice at any time and these changes will be effective for medical information we have about you as well as any information we receive in the future. We will post a copy of the current notice in the Hospital and on our website. You may also get a current copy by contacting our Privacy Officer at the phone number at end of this Notice. We are required by law to notify affected individuals following a breach of unsecured medical information.

9. Complaints. If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the United States Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint to the Hospital or the Department of Health and Human Services.

Contact the Hospital’s Regional Compliance and Privacy Officer at (903) 798-8086 if:• You have a complaint; • You have any questions about this Notice; or• You wish to obtain a form to exercise your individual rights described in section 7 of this Notice.

Wadley Senior Clinic - Joint Notice of Privacy Practices (Typeset 07-2013 Rev. 09-09-2014 ) Page 2 of 2

PATIENT RIGHTSEvery patient admitted to, or who receives care, treat-ment, and/or services at Wadley Regional Medical Center has the following rights regardless of gender, sexual orientation, race, color, age, national origin, handicap, religion, cultural, economic, or educational background or the source of payment for healthcare.

1. Considerate and respect-ful care in a setting providing personal privacy.

and respectful manner.

3. The hospital’s reason-able response to requests and needs for treatment or service, within the hospital’s capacity, its stated mission, and applicable law and regulation.

4. Effective communica-tion, including interpretation and translation services, as necessary.

5. Care that is considerate and supportive of personal values and beliefs.

6. A clean, safe, secure and pleasant environment that preserves dignity and contributes to a positive self- image.

7. Consideration of psy-chosocial, spiritual and

opinions of illness.

8. Respect to cultural and personal values, beliefs and preferences.

9. Access to community reli-gious and spiritual leaders.

10. Optimization of comfort and dignity of the dying patient, including treatment of primary and secondary symptoms that respond to treatment as directed by patient or surrogate decision maker, and effective pain management.

11. Acknowledgment of psychosocial and spiritual concerns of the patient and family regarding dying and expression of grief.

12. Have knowledge of the name of the physician who has primary responsibility for coordinating care and the names and profes-sional relationships of other physicians and healthcare providers who will see the patient.

13. Have a family member or representative and pa-

promptly upon admission to the hospital.

14. Receive information from the physician about illness, course of treatment and prospects for recovery in terms that patient can understand.

15. Receive as much infor-mation about any proposed treatment or procedure as needed in order to give in-formed consent or to refuse the course of treatment, and to make treatment

wishes. Except in emergen-cies, this information shall include a description of the procedure or treatment, the

involved in the treatment, alternate course of treat-ment or non-treatment and

and to know the name of the person who will carry out the procedure or treatment.

16. Participate actively in decisions regarding medical care. To collaborate with physicians and other health care providers in the decision making process involving health care. To the extent permitted by law, this includes the right to refuse care, treatment and services.

17. Accept medical care or to refuse treatment to the extent permitted by law and to be informed on the medi-cal consequences of such refusal.

18. Personal privacy and

within the limits of the law.

19. Full consideration of privacy concerning your medical care. Case discussions, consultation, examination and treatment

be conducted discreetly. The right to be advised as to the reason for the presence of any individual.

all communications and re-cords pertaining to care and stay in the hospital. Patient’s written permission will be obtained before medical records can be made avail-able to anyone not directly concerned with the patient’s care.

21. Access, request amend-ment to, and obtain informa-tion on disclosures of health information, in accordance with law and regulation.

22. Have the level of pain assessed and interventions provided if necessary.

23. Leave the hospital against the advice of physi-cian.

24. Reasonable continuity of care and to know in advance the time and location of appointment as well as the physician providing care.

25. Be advised if the hos-pital or personal physician proposes to engage in or perform human experimen-tation affecting patient’s care and treatment. The right to refuse to participate in such projects, and to be informed of any human experimen-tation or other research or educational projects affecting patient’s care and treatment.

26. Be informed by phy-sician or a delegate of physician of the continuing healthcare requirements following discharge from the hospital.

27. Know which hospital rules and policies apply to patient’s conduct while a patient.

28. Receive, at the time of admission, information about the hospital’s patient rights policy and the mechanism for the initiation, review and when possible, resolution of patient complaints con-cerning the quality of care received.

29. Notice of non-coverage to be provided, if indicated, upon determination of eli-

30. Full participation by patient or representative in the consideration of ethical issues that arise during care. Ethical issues in health care will be resolved by the hospital.

31. Access to the informa-tion contained in patient’s medical record, within the limits of the law.

32. The right of patient’s guardian, or next of kin, or legally authorized respon-sible person to exercise, to the extent permitted by law, the rights delineated on patient’s behalf if patient has

been adjudicated incompe-tent or found by physician to be medically incapable of understanding the proposed treatment or procedure, or are unable to communicate wishes regarding treatment, or is a minor, in accordance with the law.

33. Have practitioners and staff provide care that is consistent with the patient’s advanced directives if a valid copy is supplied to the hospital.

34. Voice grievances with respect to the treatment or care that is furnished (or fails to be furnished) without fear of discrimination or re-prisal for voicing grievances.

35. Receive care in a safe setting, free from all forms of abuse or harassment.

36. Receive a notice of

and to appeal premature discharge.

37. Receive information in a manner and form that can be understood.

38. Have or obtain an advanced directive that authorizes an agent or sur-rogate to make decisions on patient’s behalf to the extent permitted by law.

Advanced directives are written instructions rec-ognized under state law relating to the provision of health care when individuals are unable to communicate their wishes regarding medi-cal treatment. This includes the following documents: medical power of attorney for health care, a written or verbal statement (a living will), or some other form of instruction recognized

addressing the provisions of health care.

39. Have the advanced di-rective in the patient’s medi-cal record and be reviewed periodically with the patient or surrogate decision maker if the patient has executed an advanced directive.

40. Provision of care not conditioned on the existence of an advanced directive.

41. Visitation not restricted, limited, or otherwise denied based on: race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

42. Be informed of any clinically necessary or reasonable restrictions or limitations that the hospital may need to place on visita-tion rights and the reasons for the clinical restrictions or limitations.

PATIENT RESPONSIBILITIES

Every patient admitted to, or who receives care, treatment, and/or services at Wadley Regional Medi-cal Center shall have the responsibility to:

1. Provide, to the best of their knowledge, accurate and complete informa-tion concerning present complaints, past illnesses and hospitalizations, and other matters relating to their health.

2. Make it known whether they clearly comprehend the course of medical treatment and what is expected of them. Patients are encour-aged to ask questions necessary for a clear understanding of any course of action and what to expect. If nursing staff is unable to answer questions to the patient’s satisfaction, the personal physician will be

-tions patient may have.

3. Report unexpected changes in condition to the physician or nurse.

4. Follow both the treat-ment plan recommended by the physician and the

hospital’s rules and regula-tions affecting patient care and conduct, including the instructions of nurses and other health professionals as they carry out physician’s orders.

5. Accept responsibility for their actions should they refuse treatment or should they choose not to follow physician’s orders.

6. Show consideration of the rights of other patients and hospital personnel and for their behavior in the control of noise, smoking and num-ber of visitors.

7. Show respect for their own personal property, as well as the property of oth-ers and that of the organiza-tion.

obligations for their health-

as possible.

9. Follow the established policies and procedures of Wadley Regional Medical Center.

How to File a Complaint

Should you or your fam-ily members experience concerns about the care you are receiving, you may voice these concerns to the nurse or call the Care Line at 903-798-8100.

If you have a patient care or safety concern that has not been resolved by the hospi-tal staff you are encouraged to contact Administration at 1000 Pine Street, Texar-kana, TX 75501

If your concern is not resolved by hospital man-agement, you may call the Texas Department of State Health Services - 1100 West 49th Street, Austin, TX 78756 Phone: 800-963-7111 -or-The Joint Commission,

-ing - One Renaissance Bou-levard, Oakbrook Terrace, Illinois 60181Phone: 800-994-6610 Email: [email protected] -or- Center for Medicare and Medicaid Services at 1-800-633-4227.

a. Patient or support person be informed of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section.

b. Patient or support person be informed of the right, sub-ject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

c. Not restrict, limit, or other-wise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orien-tation, or disability.

d. Expect visitors to enjoy full and equal visitation privileges consistent with patient prefer-ences.

PATIENT RIGHTS & RESPONSIBILITIES

Senior Clinic Patient Rights and Responsibilities Page- Typeset 07-29-2013 Revised 09-09-2014

In order to assist you in making an informed decision regarding your care, and inaccordance with federal and state law, the following information is provided:

Wadley Regional Medical Center (the "Hospital") is a physician-owned hospital asde�ned by federal law. A list of the Hospital’s owners or investors who are physiciansor immediate family members of physicians is available upon your request.

This list will be provided to you at the time that you or your representativerequests it.

Please sign and date below:

Signature of Patient or Patient Representative

Date

Physician-Owned Hospital Acknowledgement

Physician-Owned Hospital Acknowledgement - Created: 02-27-2009 Revised: 09-09-2014

New Patient Packet - Steward Health Care System · 2018-03-26 · NEW PATIENT INFORMATION FORM...

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