PATIENT RIGHTS AND RESPONSIBILITIES

THE MEDICAL AND NURSING STAFF OF THIS FACILITY ARE COMMITTED TO SERVING OUR PATIENTS AND FAMILIES THE HIGHEST STANDARD OF CARE. PATIENTS ARE PROVIDED WITH THIS LIST OF RIGHTS AND RESPONSIBILITIES SO THAT THEY MAY PARTICIPATE IN THEIR CARE IN THE MOST EFFECTIVE MANNER.

PATIENT’S RIGHTS AS A PATIENT:

  1. You have the right to know the ownership of this facility: Harry Marshak, MD, A Professional Corporation.
  2. You have the right to be free from all forms of abuse and/or harassment.
  3. You have the right to exercise your rights without fear of discrimination or reprisal.
  4. You have the right to privacy and confidentiality regarding your office visits and records.
  5. You have the right to adequate education and counseling regarding your medical condition.
  6. You have the right to have all procedures, risks, benefits and alternatives explained, and your questions answered in laymen’s language.
  7. You have the right to have medications’ effectiveness and possible side effects explained to you.
  8. You have the right to see results of tests and have the meanings of these tests explained to you.
  9. You have the right to participate in decisions made regarding treatments, medications, procedures and surgery.
  10. You have the right to refuse treatment to the extent permitted by law and the right to receive information on alternatives and consequences of refused treatment.
  11. You have the right to review your medical records and have them explained.
  12. You have the right to have all fees explained.
  13. You have the right to decide whether or not to participate in clinical research studies.
  14. You have the right to know what we do not accept Advanced Directives. For more information on Advanced Directives you may consult the following website: http://132.239.42.18/video/sdm/AdvancedDirectiveForm.pdf
  15. You have the right to know that we will provide to you this document and all documents in a language you clearly and fully understand or will provide you with a translator for the same.
  16. You have the right to know that if you wish to file a complaint against Harry Marshak, MD, A Professional Corporation, you may contact a local California representative at: 415-744-3605. Also, you may contact the Office if the Medicare Beneficiary Ombudsman.asp.
  17. You have the right to know that you may file a grievance with Harry Marshak, MD, A Professional Corporation. Harry Marshak, MD, A Professional Corporation will investigate and evaluate your grievance and report back to you with a written response within 30 days.

PATIENT’S RESPONSIBILITIES:

  1. The center expects that a patient will provide accurate and complete information about matters relating to his/her health history in order for the patient to receive effective medical treatment.
  2. A patient is responsible for reporting whether he/she clearly comprehends a contemplated course of action and what is expected of them.
  3. The Center expects that a patient will cooperate with all Center personnel and ask a question if directions and/or procedure are not clearly understood.
  4. A patient is expected to be considerate of other patients and the Center personnel and observe the smoking policy of the Center. A patient is also expected to be respectful of the property of other persons and the property of the Center.
  5. A patient is expected to help the physicians, nurses, and allied health personnel in their efforts to care for the patient by following their instructions and medical orders both at the Center and, if applicable, outside the Center (i.e. at their home).
  6. It is understood that a patient assumes the financial responsibility of paying for any services, which are not covered by his/her insurance policies.
  7. Is it expected that the patient will not take any drugs which have not been described by his/her attending physician and/or prescribed or administered by the Center staff and shall fully disclose any drugs and/or other substances which the patient may have ingested and which could affect the current course of treatment contemplated at the center.

My signature below certifies that I have received, read, understand, and will abide by the points set forth in this document.

Date:

Signature of Patient
:_____________________________________

Date:

Signature of Witness
:_____________________________________

Print form, sign and return to
HARRY MARSHAK, MD, FACS OPHTHALMIC
PLASTIC AND FACIAL SURGERY

74-075 EL PASEO SUITE D2 PALM DESERT, CA 92260