Patient rights and responsibilities

Patient Rights and Responsibilities By State

Arizona

You have the right to:

• Be treated with dignity, respect, and consideration.
• Not be subjected to abuse, neglect, exploitation, coercion, manipulation, sexual abuse or sexual assault, restraint or seclusion (subject to A.A.C. R9-10-1012(B)), retaliation for submitting a complaint to the Arizona Department of Health Services or another entity, or misappropriation of personal or private property by an outpatient treatment center’s personnel member, employee, volunteer or student.
• Not to be discriminated against based on your race, national origin, religion, gender, sexual orientation, age, disability, marital status or diagnosis.
• Receive treatment that supports and respects your individuality, choices, strengths and abilities.
• Receive privacy in treatment and care for your needs.
• Review, upon written request, your medical records.
• Receive a referral to another health care institution if our outpatient treatment center is not authorized or able to provide the physical health services or behavioral health services you need.
• Participate or have your representative participate in the development of, or decisions concerning, your treatment.
• Participate or refuse to participate in research or experimental treatment.
• Receive assistance from a family member, your representative, or other individual in understanding, protecting or exercising your rights.
• Refuse treatment to the extent allowed by law.

You have the responsibility to: 

• Provide honest and complete information about matters that relate to your care.
• Show respect and consideration for the rights of fellow patients, the staff and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smoke-free environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility, as they arise.
• Make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed and prepared, and by adhering to any pre- and postprocedure instructions.
• Keep scheduled appointments or notify us as soon as reasonably possible if you will be delayed; If you are unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare to you or others.
• Verify with your insurance company whether SimonMed Imaging participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and noncovered services at the time service is rendered.
• Accept financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that: 

• You or your representative either consents to or refuses treatment, except in an emergency.
• You or your representative may refuse or withdraw consent before treatment is initiated.
• You or your representative is informed of alternatives to a proposed psychotropic medication or surgical procedure and any associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You or your representative is informed of our outpatient treatment facility’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to one of our outpatient treatment facilities for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law

Patient comment or complaint process:

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Arizona Department of Health Services Medical Facilities Licensing
150 N. 18th Avenue, Ste. 450 Phoenix, AZ 85007
602-364-3030

or

American College of Radiology
1891 Preston White Dr. Reston, VA 20191
703-648-8900

or

RadSite Accreditation
326 First Street, Suite 28 Annapolis, MD 21403
443-440-6007

California

You have the right to:

• Exercise these rights as set forth in California Code of Regulations, Title 22, Div. 5, Ch. 1, Art. 7, Sec. 70707, without regard to sex, economic status, educational background, race, color, religion, ancestry, national origin, sexual orientation, disability, medical condition, marital status, registered domestic partner status, or the source of payment for care.
• Considerate and respectful care.
• Knowledge of the name of the licensed healthcare practitioner who has primary responsibility for coordinating the care, and the names and professional relationships of physicians and nonphysicians who will see you.
• Receive information about the illness, the course of treatment and prospects for recovery in terms that you can understand.
• Receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternate courses of treatment or nontreatment and the risks involved in each and to know the name of the person who will carry out the procedure or treatment.
• Participate actively in decisions regarding medical care. To the extent permitted by law, this includes the right to refuse treatment.
• Full consideration of privacy concerning the medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be advised as to the reason for the presence of any individual.
• Confidential treatment of all communications and records pertaining to your care and stay in the hospital. Written permission shall be obtained before the medical records can be made available to anyone not directly concerned with the care.
• Reasonable responses to any reasonable requests made for service.
• Leave the hospital even against the advice of members of the medical staff.
• Reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of persons providing the care.
• Be advised if the hospital/licensed healthcare practitioner acting within the scope of his or her professional licensure proposes to engage in or perform human experimentation affecting care or treatment. You have the right to refuse to participate in such research projects.
• Be informed of continuing health care requirements following discharge from the hospital.
• Examine and receive an explanation of our bill regardless of source of payment.
• Know which rules and policies apply to your conduct while a patient.
• Have all your rights apply to the person who may have legal responsibility to make decisions regarding medical care on your behalf.
• Designate visitors of your choosing, if you have decision-making capacity, whether or not the visitor is related by blood, marriage, or registered domestic partner status, unless: »
  • No visitors are allowed.
  • The facility reasonably determines that the presence of a particular visitor would endanger your health or safety, a member of the health facility staff, or other visitor to the health facility, or would significantly disrupt the operations of the facility.
  • You have indicated to the health facility staff that you no longer want this person to visit.
• Have your wishes considered for purposes of determining who may visit if you lack decision-making capacity and to have the method of that consideration disclosed in our policy on visitation. At a minimum, this includes any person living in your household.

You have the responsibility to:

• Provide honest, complete information about matters that relate to your care.
• Show respect and consideration for the rights of fellow patients, the staff, and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smoke-free environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed, prepared, and adhere to any pre and post procedure instructions.
• Keep scheduled appointments or notify us if you will be delayed as soon as reasonably possible; If you are unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare or to yourself or others.
• Verify with your insurance company whether SimonMed Imaging participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance

Administrator shall ensure that:

• You or your representative either consents to or refuses treatment, except in an emergency.
• You or your representative may refuse or withdraw consent before treatment is initiated.
• You or your representative is informed of alternatives to a proposed psychotropic medication or surgical procedure and any associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You or your representative is informed of our outpatient treatment center’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to one of our outpatient treatment facilities for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law
• All SimonMed personnel observe these patients’ rights.

Patient comment or complaint process: 

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

California Department of Public Health at the nearest District Office to your SimonMed facility. You can locate the nearest District Office online at: www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/ DistrictOffices.aspx 

You may also contact them online at: www.cdph.ca.gov/Programs/CHCQ/LCP/CalHealthFind/ Pages/Complaint.aspx

or

American College of Radiology 

1891 Preston White Dr., Reston, VA 20191 

703-648-8900

or

RadSite Accreditation
326 First Street, Suite 28, Annapolis, MD 21403
443-440-6007

Colorado

You have the right to:

• Participate in all decisions involving your care or treatment.
• Be informed about whether our health care facility is participating in teaching programs, and to provide informed consent prior to being included in any clinical trials relating to the your care.
• Refuse any drug, test, procedure, or treatment and to be informed of associated risks and benefits.
• To care and treatment, in compliance with 6 CCR 1011-1 Ch. 2, that is respectful, recognizes a person’s dignity, cultural values and religious beliefs, and provides for personal privacy, to the extent possible during the course of your treatment.
• Know the names, professional status, and experience of the staff that are providing your care or treatment.
• Receive, upon request:
  • prior to initiation of care or treatment, your estimated average charge for care that is not an emergency. This includes reasonable assistance with determining the charges which may include deductibles and copayments that would not be covered by a third-party payer based on the coverage information supplied by you or your designated representative. As a health care entity, we may provide you with the estimated charge for an average patient with a similar diagnosis and inform you or your designated representative that there are variables that may alter the estimated charge. 
  • our health care general billing procedures.
  • an itemized bill that identifies treatment and services by date, which enables you to validate the charges for the items and services provided, including contact information and telephone number for billing inquiries. Our itemized bill must be made available to you within 10 business days of your request or 30 days after discharge for inpatient care, or 30 days after the service is rendered for outpatients – whichever is later. 
• Give informed consent for all treatment and procedures. It is the responsibility of the licensed independent practitioner and other health professionals to obtain informed consent for procedures that they provide to you.
• Register complaints with us and the Colorado Department of Public Health and Environment and to be informed of the procedures for registering complaints including contact information.
• Be free of abuse and neglect. As a health care entity, we are required to develop and implement policies and procedures to prevent, detect, investigate, and respond to incidents of abuse or neglect. Prevention includes, for example, adequate staffing to meet the needs of the patients, screening employees for records of abuse and neglect and protecting patients from abuse during investigation of allegations. Detection includes, but is not limited to, establishing a reporting system and training employees regarding identifying, reporting, and intervening in incidences of abuse and neglect. As a health care entity we shall investigate, in a timely manner, all allegations of abuse or neglect and implement corrective actions in accordance with such investigations.
• Be free of the inappropriate use of restraints, including improper application of a restraint or the usage of a restraint as a means of coercion, discipline, convenience, or retaliation by staff. A health care entity that does not use restraints shall include a written statement in their policies and procedures to that effect. A health care entity that does use restraints shall develop and implement policies and procedures regarding:
  • the provision of training on the use of restraints.
  • ongoing individual patient assessment to determine: when a medical condition or symptom indicates use of restraint to protect the patient or others from harm; the least restrictive intervention; and the discontinuation of the intervention at the earliest possible time
  • documentation of the use of restraint in the patient’s medical record.
• Except in emergency situations, patients shall only be accepted for care and services when our facility can meet their identified and reasonable anticipated care, treatment and service needs.
• Care delivered by us in accordance with your needs.
• Confidentiality of medical records.
• Receive care in a safe setting.
• Disclosure as to whether referrals to other providers are entities in which we have a financial interest.
• To formulate advance directives and have us and other health care entities comply with such directives, in accordance with applicable state law.

You have the responsibility to:

• Provide honest, complete information about the your health status, medical history, hospitalizations, medications and other matters that relate to your care.
• Show respect and consideration for the rights of fellow patients, the staff and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smoke-free environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed and prepared, and adhere to any pre- and post-procedure instructions.
• Participate in the development of your plan of care and then follow that plan.
• Keep scheduled appointments or notify us as soon as reasonably possible if you will be delayed; If you are unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare or to yourself or others.
• Verify with your insurance company whether SimonMed Imaging participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that:

• You or your representative either consent to or refuse treatment, except in an emergency.
• You or your representative may refuse or withdraw consent before treatment is initiated.
• You or your representative is informed of alternatives to a proposed psychotropic medication or surgical procedure and any associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You or your representative is informed of our outpatient facility’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that a you may be photographed when admitted to one of our outpatient treatment centers for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law. 

Patient comment or complaint process:

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Colorado Department of Public Health and Environment Health Facilities Division
4300 Cherry Creek Drive South, Denver, CO 80222
303-692-2800
or

American College of Radiology
1891 Preston White Dr., Reston, VA 20191
703-648-8900

or

RadSite Accreditation
326 First Street, Suite 28, Annapolis, MD 21403
443-440-6007

Florida

You have the right to:

• Be treated with courtesy and respect, with appreciation of your individual dignity and with protection of your need for privacy.
• A prompt and reasonable response to questions and requests.
• Know who is providing medical services and who is responsible for your care.
• Know what patient support services are available, including whether an interpreter is available if you do not speak English.
• Know what rules and regulations apply to your conduct.
• Be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks and prognosis.
• Refuse any treatment, except as otherwise provided by law.
• Be given, upon request, full information and necessary counseling on the availability of known financial resources for your care.
• If you are eligible for Medicare, you have the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts Medicare assignment rate.
• Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
• Receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
• Impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap or source of payment.  
• Treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
• Know if medical treatment is for purposes of experimental research and to consent or refuse to participate in such experimental research.
• Express grievances regarding any violation of your rights, as stated in Florida law, including, but not limited to, Florida Statutes, Section 381.026, through the grievance procedure of the health care provider or health care facility which served you and to the appropriate state licensing agency.

You have the responsibility to:

• Provide to the health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matter relating to your health.
• Report unexpected changes in your condition to the health care provider.
• Tell our health care provider whether you comprehend a contemplated course of action and what is expected of you.
• Follow the treatment plan recommended by the health care provider.
• Keep your appointments and, when you are unable to do so for any reason, notify the health care provider or health care facility.
• Follow the health care providers instructions and accept responsibility for your actions if you refuse treatment or do not follow the health care provider’s instructions.
• Assure that your financial obligations for health care are fulfilled as promptly as possible.
• Follow our facility rules and regulations affecting patient care and conduct.

Administrator shall ensure that:

• A patient or the patient’s representative either consents to or refuses treatment, except in an emergency.
• A patient or the patient’s representative may refuse or withdraw consent before treatment is initiated.
• A patient or the patient’s representative is informed of alternatives to a proposed psychotropic medication or surgical procedure and the associated risks and possible complications of such proposed psychotropic medication or surgical procedure, except in emergencies.
• A patient or the patient’s representative is informed of our policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to one of our outpatient treatment facilities for identification and administrative purposes.
• A patient provides written consent to release information in the patient’s medical record or financial records, except as otherwise permitted by law.

Patient comment or complaint process:

•  If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Florida Department of Health
4052 Bald Cypress Way Bin C75 Tallahassee, FL 32399

Online at https://mqa-flhealthcomplaint.doh.state.fl.us/

or

American College of Radiology
1891 Preston White Dr. Reston, VA 20191
(703) 648-8900

or

RadSite Accreditation
326 First Street, Suite 28 Annapolis, MD 21403
443-440-6007

Illinois

You have the right to:

• Receive a copy of this description of the rights afforded to you under 410 Ill. Compiled Stat. 50.
• Access care and treatment that is available and medically indicated, regardless of race, creed, sex, sexual preference, gender identity and/or preference, religious preference, national origin, disability, veteran status, sources of payment for care or any other basis prohibited by federal, state or local law.
• Considerate, respectful and dignified care with recognition of your psychosocial, spiritual, and cultural perspectives and the right to be free of all forms of abuse and harassment.
• Dying patients have the right to care which optimizes their comfort and dignity.
• Care consistent with sound nursing and medical practices within the facility’s capacity, its stated mission, and applicable laws and regulations. You do not have the right to treatment that is medically unnecessary or ineffective, ethically inappropriate, or inconsistent with the standards of good medical care.
• Knowledge of the identity and professional status of healthcare professionals providing service to you, including which physician is primarily responsible for your care.
• To have a family member or other individual and your physician notified promptly if you are admitted to a hospital as a result of the facility’s need to transfer your care.
• Reasonably informed participation in your healthcare, including clear and concise explanations of your diagnosis, prognosis, alternative procedures and forms of treatment, anticipated results, and associated risks and benefits. This includes the right to participate in the development and implementation of your plan of care.
• Designate an individual to serve as your representative in making decisions concerning your care.
• Designate a support person to be present during the course of your admission, who will receive notice of your visitation rights, and designate visitors who will receive full and equal visitation privileges consistent with your preferences and facility policy. This includes the right to consent to receive visitors (including a spouse or domestic partner, including a same-sex domestic partner, another family member, or a friend) or to deny consent to receive specific visitors, either orally or in writing. You have the right to be informed of the basis for any limitations or restrictions of your visitation rights under facility policy.
• Accept or refuse treatment and to be informed of the medical consequences of any refusal.
• Consent to or decline to participate in proposed research studies and to have those studies fully explained prior to consent. The decision to refuse participation or withdraw from a research study will not affect your care.
• Reasonable personal safety while receiving care.
• Receive information about your care in a language you can understand.
• Request and receive an itemized copy and/or explanation of your charges.
• Receive information and participate in decisions related to effective management of pain.
• Personal privacy consistent with your care needs and to receive a paper copy of the facility’s Notice of Privacy Practices, which describes your rights regarding confidentiality of your health information under the Federal Privacy Rule (HIPAA).
• Remain free from restraint unless there is appropriate clinical justification to protect you from harming yourself or others.
• Access bioethics consultation if you or your family deem necessary.

You have the responsibility to:

• Provide honest, complete information about matters that relate to your care.
• Show respect and consideration for the rights of fellow patients, the staff, and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smoke-free environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed, prepared, and adhere to any pre and post procedure instructions.
• Keep scheduled appointments or notify us if you will be delayed as soon as reasonably possible; or, if unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare or to yourself or others.
• Verify with your insurance company whether SimonMed participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that:

• You (or your representative) either consent to or refuse treatment, except in an emergency.
• You (or your representative) may refuse or withdraw consent before treatment is initiated.
• You (or your representative) are informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You (or your representative) are informed of our outpatient treatment center’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except you may be photographed when admitted to an outpatient treatment center for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law.

Patient comment or complaint process:

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Illinois Department of Public Health Office of Health Care Regulation
525 W. Jefferson Street, 5th Floor Springfield, IL 62761
800-252-4343

or

American College of Radiology
1891 Preston White Dr. Reston, VA 20191
703-648-8900

or

RadSite Accreditation
326 First Street, Suite 28 Annapolis, MD 21403
443-440-6007

Kentucky

You have the right to:

• Be treated in a dignified and respectful manner and to receive reasonable responses to reasonable requests for service.
• To effective communication that provides information in a manner you understand, in your preferred language with provisions of interpreting or translation services, at no cost, and in a manner that meets your needs in the event of vision, speech, hearing or cognitive impairments. Information should be provided in easy to understand terms that will allow you to formulate informed consent.
• Respect for your cultural and personal values, beliefs and preferences.
• Personal privacy, privacy of your health information and to receive a notice of the facility’s privacy practices.
• Pain management.
• Accommodation for your religious and other spiritual services.
• To access, request amendment to and obtain information on disclosures of your health information in accordance with law and regulation within a reasonable time frame.
• To have a family member, friend or other support individual be present with you during the course of your stay, unless that person’s presence infringes on others’ rights, safety or is medically contraindicated.
• Care or services provided without discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.
• Participate in decisions about your care, including developing your treatment plan, discharge planning and having your family and personal physician promptly notified of your admission.
• Select providers of goods and services to be received after discharge.
• Refuse care, treatment or services in accordance with law and regulation and to leave the facility against advice of the physician.
• Have a surrogate decision-maker participate in care, treatment and services decisions when you are unable to make your own decisions.
• Receive information about the outcomes of your care, treatment and services, including unanticipated outcomes.
• Give or withhold informed consent when making decisions about your care, treatment and services.
• Receive information about benefits, risks, side effects to proposed care, treatment and services; the likelihood of achieving your goals and any potential problems that might occur during recuperation from proposed care, treatment and service and any reasonable alternatives to the care, treatment and services proposed.
• Give or withhold informed consent to recordings, filming or obtaining images of you for any purpose other than your care.
• Participate in or refuse to participate in research, investigation or clinical trials without jeopardizing your access to care and services unrelated to the research.
• Know the names of the practitioner who has primary responsibility for your care, treatment or services and the names of other practitioners providing your care.
• Formulate advance directives concerning care to be received at end-of-life and to have those advance directives honored to the extent of the facility’s ability to do so in accordance with law and regulation. You also have the right to review or revise any advance directives.
• Be free from neglect; exploitation; and verbal, mental, physical and sexual abuse.
• An environment that is safe, preserves dignity and contributes to a positive self-image.
• Be free from any forms of restraint or seclusion used as a means of convenience, discipline, coercion or retaliation; and to have the least restrictive method of restraint or seclusion used only when necessary to ensure patient safety.
• Access protective and advocacy services and to receive a list of such groups upon your request.
• Receive the visitors whom you designate, including but not limited to a spouse, a domestic partner (including same-sex domestic partner), another family member, or a friend. You may deny or withdraw your consent to receive any visitor at any time. To the extent this facility places limitations or restrictions on visitation; you have the right to set any preference of order or priority for your visitors to satisfy those limitations or restrictions.
• Examine and receive an explanation of the bill for services, regardless of the source of payment.

You have the responsibility to:

• Provide, to the best of your knowledge, accurate, honest, and complete information about matters that relate to your care, including information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health.
• Report unexpected changes in your condition to the physician or other professionals who are responsible for your care.
• Show respect and consideration for the rights of fellow patients, the staff, and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smokefree environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Honestly make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed, prepared, and adhere to any pre and post procedure instructions.
• Keep scheduled appointments or notify us if you will be delayed as soon as reasonably possible; or, if unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare or to yourself or others.
• Verify with your insurance company whether SimonMed participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that:

• You (or your representative) either consent to or refuse treatment, except in an emergency.
• You (or your representative) may refuse or withdraw consent before treatment is initiated.
• You (or your representative) are informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You (or your representative) are informed of the outpatient treatment center’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to an outpatient treatment center for identification and administrative purposes.
• You provide written consent to release information in your medical records or financial records, except as otherwise permitted by law.

Patient comment or complaint process:

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Kentucky Cabinet for Health and Family Services
275 E. Main St. Frankfort, KY 40621
502-595-4079

Kentucky Cabinet for Health Services Office of Inspector General Division of Licensing and Regulations
908 W. Broadway Louisville, KY 40203
502-595-4079

or

American College of Radiology
1891 Preston White Dr. Reston, VA 20191
703-648-8900

or

RadSite Accreditation
326 First Street, Suite 28 Annapolis, MD 21403
443-440-6007

Nevada

You have the right to:

• Receive a copy of this description of the rights afforded to you under Nevada Rev. Statutes 449.700–730.
• Receive considerate and respectful care.
• Refuse treatment to the extent permitted by law and to be informed of the consequences of that refusal.
• Refuse to participate in any medical experiments conducted at the facility. • Retain your privacy concerning your program of medical care.
• Have any reasonable request for services reasonably satisfied by our facility considering our ability to do so.
• Receive continuous care from our facility.
• Be informed:
  • Of your appointments for treatment and the names of the persons available at the facility for those treatments; and
  • By your physician or an authorized representative of the physician, of your need for continuing care. 
• Confidentiality of all discussions of your care, consultations with other persons concerning your care, examinations or treatments, and all communications and records concerning your care.
• Consent to the presence of any person who is not directly involved with your care during any examination, consultation or treatment.
• Receive information concerning any other medical or educational facility or facility which relates to your care.
• Obtain information concerning the professional qualifications or associations of the persons who are treating you.
• Receive the name of the person responsible for coordinating your care in the facility.
• Be advised if the facility in which you are a patient proposes to perform experiments on patients which affect your own care or treatment.
• Receive from your physician a complete and current description of your diagnosis, plan for treatment and prognosis in terms which you are able to understand. If it is not medically advisable to give this information to you, the physician shall:
  • Provide the information to an appropriate person responsible for you; and 
  • Inform that person that he or she shall not disclose the information to you. 
• Receive from your physician the information necessary for you to give your informed consent to a procedure or treatment. Except in an emergency, this information must not be limited to a specific procedure or treatment and must include:
  • A description of the significant medical risks involved;
  • Any information on alternatives to the treatment or procedure if you request that information; 
  • The name of the person responsible for the procedure or treatment; and 
  • The costs likely to be incurred for the treatment or procedure and any alternative treatment or procedure. 
• Examine the bill for your care and receive an explanation of the bill, whether or not you are personally responsible for payment of the bill.
• Know the regulations of the facility concerning your conduct at the facility.
• Receive, within reasonable restrictions as to time and place, visitors of your choosing, including, your friends and family, and to designate such persons in writing in the event that you are unable to communicate such authorization to the staff of the facility.
• Be transferred to another facility in the event the facility cannot properly treat you and to receive an explanation of the need to transfer you to another facility and the alternatives available to the transfer.

You have the responsibility to:

• Provide honest, complete information about matters that relate to your care.
• Show respect and consideration for the rights of fellow patients, the staff and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smoke-free environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed and prepared and by adhering to any pre- and post-procedure instructions.
• Keep scheduled appointments or notify us as soon as reasonably possible if you will be delayed; if you are unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage. • Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare to you or others.
• Verify with your insurance company whether SimonMed Imaging participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that:

• You or your representative either consents to or refuses treatment, except in an emergency.
• You or your representative may refuse or withdraw consent before treatment is initiated.
• You or your representative are informed of alternatives to proposed psychotropic medication or surgical procedure and the associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You or your representative are informed of our outpatient treatment facility’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to our outpatient treatment facility for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law. 

Patient comment or complaint process:

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Nevada Department of Health and Human Services
Division of Public and Behavioral Health Bureau of Health Care Quality and Compliance
4220 S. Maryland Parkway, #D-810, Las Vegas, NV 89119
702-668-3250

or

American College of Radiology
1891 Preston White Dr., Reston, VA 20191
703-648-8900

or

RadSite Accreditation
326 First Street, #28, Annapolis, MD 21403
443-440-6007

New York

You have the right to:

• Receive a copy of this description of the rights afforded to you under New York State law and as described in the New York State Department of Health Publication 1515 (rev. Feb. 2019 (and similar to the rights afforded under NY Consolidated Laws, Public Health Law § 2803 and 10 NYCRR, §§ 405.7, noting that SimonMed is not a hospital subject to the requirements thereunder).
• Receive treatment without discrimination as to race, color, religion, sex, gender identity, national origin, disability, sexual orientation, age or source of payment.
• Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.
• Receive emergency care if you need it.
• Be informed of the name and position of the doctor who will be in charge of your care in the facility.
• Know the names, positions and functions of any facility staff involved in your care and refuse their treatment, examination or observation.
• Identify a caregiver who will be included in your discharge planning and sharing of post-discharge care information or instruction.
• Receive complete information about your diagnosis, treatment and prognosis.
• Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.
• Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet: “Deciding About Health Care— A Guide for Patients and Families.”
• Refuse treatment and be told what effect this may have on your health.
• Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation.
• Privacy while in the facility and confidentiality of all information and records regarding your care.
• Participate in all decisions about your treatment and discharge from the facility. The facility must provide you with a written discharge plan and written description of how you can appeal your discharge.
• Review your medical record without charge, and obtain a copy of your medical record for which the facility can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay.
• Receive an itemized bill and explanation of all charges.
• View a list of the facility’s standard charges for items and services and the health plans the facility participates with.
• Challenge an unexpected bill through the Independent Dispute Resolution process.
• Complain without fear of reprisals about the care and services you are receiving and to have the facility respond to you and if you request it, a written response. If you are not satisfied with the facility’s response, you can complain to the New York State Health Department. The facility must provide you with the State Health Department telephone number.
• Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.
• Make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as health care proxy, will, donor card, or other signed paper). The health care proxy is available from the facility.
• Receive an estimate of the amount you will be billed after services are rendered.

You have the responsibility to:

• Provide, to the best of your knowledge, accurate, honest, and complete information about matters that relate to your care, including information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health.
• Report unexpected changes in your condition to the physician or other professionals who are responsible for your care.
• Show respect and consideration for the rights of fellow patients, the staff, and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smoke-free environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Honestly make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed, prepared, and adhere to any pre and post procedure instructions.
• Keep scheduled appointments or notify us if you will be delayed as soon as reasonably possible; or, if unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare or to yourself or others.
• Verify with your insurance company whether SimonMed participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that:

• You (or your representative) either consents to or refuses treatment, except in an emergency.
• You (or your representative) may refuse or withdraw consent before treatment is initiated.
• You (or your representative) are informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You (or your representative) are informed of the outpatient treatment center’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to an outpatient treatment center for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law.

Patient comment or complaint process:

• You or your representative have the right to report any concerns to:

New York State Department of Health Office of Professional Medical Conduct,
Central Intake Unit Riverview Center
150 Broadway, Suite 355, Albany, NY 12204
518-402-0836

or

American College of Radiology
1891 Preston White Dr., Reston, VA 20191
703-648-8900

or
RadSite Accreditation
326 First Street, #28, Annapolis, MD 21403
443-440-6007

Texas

You have the right to:

• Receive a copy of this description of the rights afforded to you under Texas Health and Safety Code § 321.002.
• Receive access to equal medical treatment and accommodations regardless of your race, creed, sex, national origin, religion or sources of payment for care.
• Be fully informed and have complete information, to the extent known by the physician, regarding diagnosis, treatment, procedure and prognosis, as well as the risks and side effects associated with your treatment and procedure prior to the procedure.
• Exercise your rights without being subjected to discrimination or reprisal.
• Voice grievances regarding treatment or care that is (or fails to be) furnished. • Personal privacy.
• Receive care in a safe setting.
• Be free from all forms of abuse or harassment.
• Receive the care necessary to regain or maintain your maximum state of health and if necessary, cope with death.
• 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 services.
• Be fully informed of the scope of services available at our facility, provisions for after-hours care and related fees for services rendered.
• Be a participant in decisions regarding the intensity and scope of your treatment. If you are unable to participate in those decisions, your rights shall be exercised by your designated representative or other legally designated person.
• Make informed decisions regarding your care.
• Refuse treatment to the extent permitted by law and be informed of the medical consequences of such refusal. You accept responsibility for your actions should you refuse treatment or not follow the instructions of the physician or facility.
• Approve or refuse the release of medical records to any individual outside the facility, or as required by law or third party payment contract.
• Be informed of any human experimentation or other research or educational projects affecting your care of treatment. You can refuse participation in such experimentation or research without compromise to your usual care.
• Express grievances/complaints and suggestions at any time.
• Access to and/or copies of your medical records.
• Be informed as to the facility’s policy regarding advance directives/living wills.
• Be fully informed before any transfer to another facility or organization and ensure the receiving facility has accepted your transfer.
• Express those spiritual beliefs and cultural practices that do not harm or interfere with the planned course of medical therapy for you.
• Expect the facility to agree to comply with Federal Civil Rights Laws that assure it will provide interpretation for individuals who are not proficient in English.
• Have an assessment and regular assessment of pain.
• Education of patients and families, when appropriate, regarding their roles in managing pain.
• To change providers if other qualified providers are available.
• If a patient is adjudged incompetent under applicable state health and safety laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under state law to act on the patient’s behalf.
• If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state laws may exercise the patient’s rights to the extent allowed by state law. 

You have the responsibility to:

• Provide, to the best of your knowledge, accurate, honest, and complete information about matters that relate to your care, including information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health.
• Report unexpected changes in your condition to the physician or other professionals who are responsible for your care.
• Show respect and consideration for the rights of fellow patients, the staff, and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smoke-free environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Honestly make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed, prepared, and adhere to any pre and post procedure instructions.
• Keep scheduled appointments or notify us if you will be delayed as soon as reasonably possible; or, if unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare or to yourself or others.
• Verify with your insurance company whether SimonMed participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that:

• You (or your representative) are either consent to or refuse treatment, except in an emergency.
• You (or your representative) are may refuse or withdraw consent before treatment is initiated.
• You (or your representative) are informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies. • You (or your representative) are informed of the outpatient treatment center’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to an outpatient treatment center for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law.

Patient comment or complaint process:

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Texas Health and Human Services Commission
Complaint and Incident Intake, Mail Code E-249
PO Box 149030, Austin, TX 78714
888-973-0022

or

American College of Radiology
1891 Preston White Dr., Reston, VA 20191
703-648-8900

or

RadSite Accreditation
326 First Street, #28, Annapolis, MD 21403
443-440-6007

Wisconsin

You have the right to:

• Receive a copy of this description of the rights afforded to you under this notice (that are similar to those described under Wisc. Admin Code HFS § 124.05, noting that SimonMed is not a Critical Access Hospital subject to the requirements thereunder).
• Receive safe, quality care through the services that the facility provides.
• Receive care and have visitation privileges without being discriminated against because of age, race, color, national origin, language, religion, culture, disability, sex, gender identity or expression, sexual orientation, or ability to pay.
• Choose who can and cannot visit you, without regard to legal relationship, race, color, national origin, religion, sex, sexual orientation, gender identity or disability. You may withdraw or deny consent for visitation at any time.
• Be informed when the facility restricts your visitation rights for your health or safety, or the health or safety of patients, employees, physicians or visitors.
• Be treated with respect and dignity and be protected from abuse, neglect, exploitation and harassment.
• Have your own physician and/or a family member, support person, or other individual be notified promptly if you are transferred to another facility.
• Know the names and roles of facility staff caring for you.
• Have a family member, support person, or other individual present with you for emotional support during the course of your stay, unless the individual’s presence infringes on others’ rights, safety, or is medically or therapeutically contraindicated.
• Have a family member, support person, or other individual involved in treatment decisions or make health care decisions for you, to the extent permitted by law.
• Have an Advance Directive (health care directive, durable power of attorney for health care, or living will) that states your wishes and values for health care decisions when you cannot speak for yourself.
• Be informed about your health problems, treatment options, and likely or unanticipated outcomes so you can take part in developing, implementing and revising your plan of care.
• Have information about the outcome of your care, including unanticipated outcomes.
• Request, accept and/or refuse care, treatment or services as allowed by our facility’s policy and the law, and be informed of the medical consequences of your refusal of care.
• Ask for a change of care provider or a second opinion.
• Have information provided to you in a manner that meets your needs and is tailored to your age, preferred language, and ability to understand.
• Have access to an interpreter and/or translation services to help you understand medical and financial information.
• Have your pain assessed and managed.
• Have privacy and confidentiality when you are receiving care.
• Practice and seek advice about your cultural, spiritual and ethical beliefs, as long as this does not interfere with the wellbeing of others.
• Request assistance to help you work through difficult decisions about your care.
• If necessary, any form of restraint or seclusion will be performed in accordance with safety standards required by state and federal law.
• Have a safe environment, including zero tolerance for violence, and the right to use your clothes and personal items in a reasonably protected environment.
• Take part in decisions about restricting visitors, mail or phone calls.
• Receive protective oversight while a patient in the facility, and receive a list of patient advocacy services.
• Review your medical record and receive answers to questions you may have about it. You may request amendments to your record and may obtain copies as permitted by law at a fair cost in a reasonable time frame.
• Have your records kept confidential; they will only be shared with your caregivers and those who can legally see them. You may request information on who has received your record.
• Receive a copy of and details about your bill.
• Ask about and be informed of business relationships among payors, hospitals, educational institutions, and other health care providers that may affect your care.
• Submit a concern regarding your care. The facility maintains a grievance process for the resolution of concerns, which you may submit directly to us. You should expect to receive a timely verbal or written response, as requested or otherwise required by law and policy. If you have a concern, please contact your care provider or the manager of the patient care area where you are receiving care.

You have the responsibility to:

• Provide, to the best of your knowledge, accurate, honest, and complete information about matters that relate to your care, including information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health.
• Report unexpected changes in your condition to the physician or other professionals who are responsible for your care.
• Show respect and consideration for the rights of fellow patients, the staff, and our property.
• Ask questions when you do not understand information or instructions.
• Comply with the rules of our facility, including our visitor and smokefree environment policies.
• Express your opinions, concerns or complaints in a constructive manner to the appropriate people at our facility as they arise.
• Honestly make it known whether or not you understand the care and diagnostic tests to be performed and take an active role in your treatment by being informed, prepared, and adhere to any pre and post procedure instructions.
• Keep scheduled appointments or notify us if you will be delayed as soon as reasonably possible; or, if unable to keep scheduled appointments, notify us 24 hours in advance.
• Relay any current medication(s) you are taking or any medical allergies to a healthcare provider.
• Learn how to access information pertaining to your health care coverage.
• Inform us about any living will, medical power of attorney, or other directive that may affect your care.
• Behave in a manner that is not disruptive to the delivery of healthcare or to yourself or others.
• Verify with your insurance company whether SimonMed participates with your insurance plan and if you have deductibles and/or co-pays.
• Present your insurance card and proper identification prior to receiving services.
• Pay all charges, if any, for appointments and non-covered services at the time service is rendered.
• Accept personal financial responsibility for any charges not covered by your insurance.

Administrator shall ensure that:

• You (or your representative) are either consents to or refuses treatment, except in an emergency.
• You (or your representative) may refuse or withdraw consent before treatment is initiated.
• You (or your representative) are informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure, except in emergencies.
• You (or your representative) are informed of the outpatient treatment center’s policy on health care directives and the patient complaint process.
• You consent to a photograph before being taken, except that you may be photographed when admitted to an outpatient treatment center for identification and administrative purposes.
• You provide written consent to release information in your medical record or financial records, except as otherwise permitted by law.

Patient comment or complaint process:

• If at any time you have questions or concerns regarding your Rights and Responsibilities, please ask to speak with the manager of our facility or contact our Compliance Department by phone at 602-688-6116.
• You or your representative have the right to report any concerns to: 

Wisconsin Division of Quality Assurance
PO Box 2969 Madison, WI 53701
608-266-8481

or

American College of Radiology
1891 Preston White Dr. Reston, VA 20191
703-648-8900

or

RadSite Accreditation
326 First Street, #28 Annapolis, MD 21403
443-440-6007