Patient Rights and Responsibilities Form

As the accredited Medical and Dental Home of our patients, NATIVE HEALTH is committed to the following Patient Rights and Responsibilities. Patients have a fundamental right to medical care that safeguards their personal dignity and respects their cultural, psychosocial, and spiritual values. NATIVE HEALTH strives to provide understanding and respect of these values in meeting patients’ needs as long as these values are within the health center’s capacity, its stated mission and philosophy, and relevant laws and regulations. We honor and attest to your rights as a patient to:

ACCESSIBLE CARE

• Receive medical, dental, and behavioral health care that supports and respects your individuality, choices, strengths, and abilities.
• Communicate and receive a timely response to your concerns by contacting a NATIVE HEALTH employee.
• Receive assistance with protective services if necessary.
• Receive referrals to other health care professionals if Native Health is not authorized or unable to provide the physical or behavioral health services you need.
• Change providers if other qualified providers are available.

CONFIDENTIALITY

• Protect your personal privacy concerning your medical and overall health care.
• Have communications, health information, and records pertaining to your care treated as confidential.
• Conduct case discussion, consultation, examination and treatment confidentially and discreetly.
• Not have staff present without your permission unless they are involved directly in your care.

COORDINATION OF CARE

• Participate, or have your representative participate, in the development of or decisions concerning your care plan along with your chosen family.
• Know the name of your primary medical, dental or behavioral health provider.
• Know the names and professional titles of caregivers participating in your care.
• Participate in the development and implementation of your care plan.
• Appoint a representative of your choice to make informed decisions about your care.

INFORMATION, EDUCATION AND COMMUNICATION

• Receive complete and current information about your diagnosis, condition, and treatment and outcomes of care, including unanticipated outcomes, in a manner that you can understand
• Except in an emergency, be 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.
• Receive Native Health’s policies on Advance Directives/Living Wills and have your stated wishes honored.
• Receive and examine an explanation of charges, regardless of source of payment in a manner that you can understand.
• Receive health information and education to optimize your health and self-management.
• Receive access to your health information as permitted by state and federal law and receive your health information by reasonable alternative means or at an alternative location.
• Except as permitted by law, provide written consent to the release of information in your medical and financial records.
• Be informed of the process for submitting complaints to Native Health.

TRANSITION AND CONTINUITY OF CARE

• Expect reasonable continuity of care and be advised of continuing healthcare requirements

PHYSICAL COMFORT

• Be cared for in a healing environment which is dean, safe and respectful of your personal privacy and care for personal needs.
• Receive appropriate pain assessment and management with the intention to maximize your comfort.

RESPECT AND DIGNITY

• Make informed choices about your care and treatment, including, except in an emergency, to consent to care, to refuse treatment or to refuse or withdraw consent before treatment is initiated.
• Express concerns, be heard, and receive an appropriate response.
• Not be discriminated against based on race, color, creed, ethnic or national origin, cultural background, religion or belief, age, sex, gender identity, gender expression, sexual orientation, economic status, education, disability, marital status or diagnosis.
• Not be subjected to abuse, neglect, exploitation, coercion, manipulation, sexual abuse, sexual assault, restraint or seclusion, retaliation for submitting a complaint to the Arizona Department of Health Services or other entity, or misappropriation of personal and private property by NATIVE HEALTH’s personnel member, employee volunteer, or student.
• 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 patient rights.
• Consent before your picture is taken, except that you may be photographed for identification and administrative purposes.

RATES AND CHARGES

• If you are self-pay or uninsured, request a good faith estimate of expected charges.
• Request an explanation regarding payment made by your insurance company.
• Obtain a schedule of Native Health’s rates and charges required in A.R.S. § 36-436.01(C).
• Notify the receptionist or clerk regarding this request. You may also find pricing for services posted in our reception area and on our website at: https://www.nativehealthphoenix.org

PATIENT RESPONSIBILITIES

As a partner on your healthcare team, we ask you to:

• Provide complete and accurate information about your current and past state of health, including allergies or sensitivities ,past illnesses, hospitalizations, and the medications you are taking, including over-the-counter medications and dietary supplements.
• Report changes in your condition or symptoms, including pain, to a member of the healthcare team.
• Talk to us about your pain and options for minimizing it.
• Ask questions when you do not understand what we are saying or asking you to do.
• Follow the treatment plan that you developed with your healthcare providers and participate in your care.
• Accept responsibility for your health outcome, if you choose not to follow your treatment plan.
• Follow the rules and regulations of our health center, which have been put in place for your safety and the safety of others. This may include providing a responsible adult to provide you transportation and staying with you as directed by your health care provider.
• Assist us in providing a safe environment by sharing your observations if you perceive unsafe conditions or practices.
• Show respect and consideration for your healthcare professionals and other patients and families by controlling noise and disturbances, not smoking, respecting others’ property, and not bringing any weapons into our clinic.
• Assure your financial obligation for health care is fulfilled as promptly as possible.
• Adhere to all infection control policies and procedures including all present COVID-19 safety protocols.

If you would like to express a concern or complaint about your care, treatment or safety, please contact the Quality Assurance Manager. Brian Robles x 602-279-5262 X 11003 Email: brobles@nachci.com A copy of the Patient Rights and Responsibilities Policy is available at the front desk.

Patient/Guardian Signature