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Pre-Registration Form


PATIENT RIGHTS AND RESPONSIBILITIES

* indicates required information

** indicates required if applicable

THE PATIENT HAS THE RIGHT TO:

  • Receive the care necessary to regain or maintain his or her maximum state of health and if necessary, cope with death.

  • Expect personnel who care for the patient 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 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 treatment and procedure prior to the procedure.

  • Be fully informed of the scope of services available at the facility, provisions for after-hours and emergency care and related fees for services rendered.

  • Be a participant in decisions regarding the intensity and scope of treatment. If the patient is unable to participate in those decisions, the patient's rights shall be exercised by the patient's designated representative or other legally designated person.

  • Make informed decisions regarding his or her care.

  • Refuse treatment to the extent permitted by law and be informed of the medical consequences of such refusal. The patient accepts responsibility for his or her actions should he or she refuse treatment or not follow the instructions ofthe 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/educational projects affecting his or her care of treatment and can refuse participation in such experimentation or research without compromise to the patient's usual care.

  • Express grievances/complaints and suggestions at any time.

  • Be given assistance in changing primary care or specialty physicians if other qualified physicians are available.

  • Provide patient access to and/or copies of his/her 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 the patient transfer.

  • Express those spiritual beliefs and cultural practices that do not harm or interfere with the planned course of medical therapy for the patient.

  • 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. The facility presents information in a manner and form, such as TOO, large print materials and interpreters, that can be understood by hearing and sight impaired individuals.

  • Have an assessment and regular assessment of pain.

  • Education of patients and families, when appropriate, regarding their roles in managing pain, as well as potential limitations and side effects of pain treatment, if applicable.

  • Have their personal, cultural, spiritual and/or ethnic beliefs considered when communicating to them and their families about pain management and their overall care.

  • Exercise his or her 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.

  • 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.

*Patient Initials


PATIENT RESPONSIBILITES:

  • Be considerate of other patients and personnel and for assisting in the control of noise, smoking and other distractions.

  • Respecting the property of others and the facility.

  • Reporting whether he or she clearly understands the planned course of treatment and what is expected of him or her.

  • Keeping appointments and, when unable to do so for any reason, notifying the facility and physician

  • Providing care givers with the most accurate and complete information regarding present complaints, past illnesses and hospitalizations, medications, unexpected changes in the patient's condition or any other patient health matters.

  • Observing prescribed rules of the facility during his or her stay and treatment and, if instructions are not followed, forfeiting the right to care at the facility and is responsible for the outcome.

  • Promptly fulfilling his or her financial obligations to the facility.

  • Payment to facility for copies of the medical records the patient may request.

  • Identifying any patient safety concerns.


  • ADVANCE DIRECTIVE NOTIFICATION:

    In the State of Georgia, all patients have the right to participate in their own health care decisions and to make Advance Directives or to execute Powers of Attorney that authorize others to make decisions on their behalf based on the patient's expressed wishes when the patient is unable to make decisions or unable to make decisions or unable to communicate decisions. The Surgery Center respects and upholds those rights.

    However, unlike in an acute care hospital setting, The Surgery Center does not routinely perform "high risk" procedures. Most procedures performed in this facility are considered to be of minimal risk. Of course, no surgery is without risk. You will discuss the specifics of your procedure with your physician who can answer your questions as to its risks, your expected recovery, and care after your surgery.

    Therefore, it is our policy, regardless of the contents of any Advance Directive or instructions from a health care surrogate or attorney-in-fact, that if an adverse event occurs during your treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. At the acute care hospital, further treatments or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive, or health care Power of Attorney. Your agreement with this facility's policy will not revoke or invalidate any current health care directive or health care power of attorney.

    If you wish to complete an Advance Directive, copies of the official State forms are available at our facility.

    If you do not agree with this facility's policy, we will be pleased to assist you in rescheduling your procedure.


    PATIENT COMPLAINT OR GRIEVANCE:

    To report a complaint or grievance you can contact the facility Administrator by phone at 706-323-8803 or by mail at:
    The Surgery Center, LLC
    2548 Weems Road
    Columbus, GA 31909
    Attn: Sharon Johnson

    You may also contact AAAHC by mail at:
    Accreditation Association for Ambulatory Health Care, INC.
    5250 Old Orchard Road, Suite 200
    Skokie, Illinois 60077

    Complaints and grievances may also be filed through the State of Georgia Office of Investigations at:
    Georgia Department of Human Resources
    Two Peachtree Street NW
    Atlanta, Georgia 30303-3186
    Phone: 404-657-5726

    All Medicare beneficiaries may also file a complaint or grievance with the Medicare Beneficiary Ombudsman.
    Visit the Ombudsman's webpage on the web at:
    www.cms.hhs.gov/center/ombudsman.asp





Personal Information
Gender*

Last Name* First Name* MI*

Last 4 of SS* Marital Status * DOB *
Contact Information Home Address* City* State* Zip*

**Mailing Address** City State Zip

Home Phone** () - Cell Phone** () - Other Phone** () -
Emergency Contact* Name* Phone* () -
Employement Information Are you a student?* (PT or FT)**

Employment Status* Occupation**

Employer Name**

Employer Address** City State Zip Employer Phone** () -
** If the insurance of the patient is not in the patient's name then we need the following on the policyholder:
Last Name* First Name* MI* SS* - -

Home Address* City State Zip

Home Phone** () - Cell Phone** () -

Employer Name* Employer Phone* () -

Employer Address* City* State* Zip*
** If you are retired military but have another insurance because you are currently employed or retired from another employer besides the military, then we need other employment information:

Employer Name* Employer Phone* () -

Employer Address* City* State* Zip*







*Full Legal Name: *Date: / /

BY DIGITALLY SIGNING THIS DOCUMENT, I ACKOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS, AND AGREE TO THE TERMS AND CONDITIONS, AND SWEAR THAT THE INFORMATION GIVEN IS CORRECT TO THE BEST OF MY KNOLODGE:

PLEASE REVIEW FORM BEFORE SUBMITTING

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