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Patient's Rights and Responsibilites Statement
Statement of Patient’s Rights
Patients have the rights to be treated with dignity and respect.
Patients have the right to fair treatment. This is regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.
Patients have the right to have their treatment and other member information kept private.
Only in an emergency, or if required by law, can records be released without patient permission.
Patients have the right to information from staff/providers in a language they can understand.
Patients have the right to an easily understood explanation of their condition and treatment.
Patients have the right to know all about their treatment choices, regardless of cost or if the costs are covered by their insurance company or not.
Patients have the right to information about Luzio & Associates Behavioral Services and their provider’s role in the treatment process.
Patients have the right to information about their provider’s clinical qualifications.
Patients have the right to know the guidelines used in providing and/or managing their care.
Patients have the right to know about the complaint, grievance and appeal process.
Patients have the right to that there may be State and Federal Laws that relate to their rights and responsibilities.
Patients have the right to know their rights and responsibilities in the treatment process.
Patients have the right to share in the information of their plan of care.
Statement of Patient’s Responsibilities
Patients have the responsibility to give provider’s needed information, so that the provider can deliver the best possible care.
Patients have the responsibility to let their provider know then the treatment plan no longer works for them.
Patients have the responsibility to follow their medication plan. They must tell their provider about medication changes.
Patients have the responsibility to treat those giving them care with dignity and respect.
Patients should not take actions that could harm the lives of Luzio & Associates employees, providers, or other patients.
Patients have the responsibility to keep their appointments. Patients should call Luzio & Associates Behavioral Services’ office as soon as possible if they need to change or cancel appointments. If appointments are cancelled with less than 24 hours’ notice or the patient does not show on three occasions then that client can not longer be seen by any providers at Luzio & Associates.
Patients have the responsibility to ask their providers questions about their care. This is so they can understand their care and their role in that care.
Patients have the responsibility to follow the plans and instructions for their care. The care is to be agreed upon by the patient and provider.
Patients have the responsibility to pay in a timely manner.
Patients have the responsibility to understand the scope and limitations of their insurance policies.
I have read and understand my Patient Rights and Responsibilities.
Signature of Patient of Legal Representative
Relationship to Patient
Patient Name
Date
Signature of Provider
Date
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