Patient Rights & Responsibilities

Marietta Eye Clinic

Patient Rights & Responsibilities

As a patient you have the right to:

1. Become informed of rights as a patient in advance of, or when discontinuing, the provision of care. The patient
may appoint a representative to receive this information should patient so desire.

2. Be treated with dignity and receive considerate and respectful care provided in a safe environment.
3. Remain free from seclusion or restraints of any form that are not medically necessary or are used as a means of
coercion, discipline, convenience or retaliation by staff.

4. Exercise these rights without regard to age, race, disability, sex or cultural, economic, education, or religious
background or the source of payment for care given.

5. Knowledge of the name of the physician and professional staff who have primary responsibility for coordinating the
patient’s care and the name and professional relationships of other physicians and non-physicians who will
participate in care.

6. Receive information from the physician about the illness, course of treatment and prospects for recovery in terms
that the patient can understand.

7. Receive as much information about any proposed treatment or procedure as needed 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 course of treatment
or non-treatment and the risks involved in each and to know the name of the person who will carry out the
procedure or treatment.

8. Participate actively in decisions regarding medical care. To the extent permitted by law, this includes the right to
request and/or refuse treatment.

9. Provide a copy of an advance directives regarding patient’s healthcare, and have the surgery center make this
apart of the medical record. In the unlikely event of an emergency all patient will be given emergency care.

10. Have a family member or representative notified promptly of admission to the surgery center.

11. Have personal physician notified promptly of admission to the surgery center.

12. Know that you can express a complaint regarding your care or any violation of your rights, and that you’re doing so
will not adversely affect the quality of care provided.

13. Be advised of the ’s grievance process, should the patient wish to communicate a concern regarding the quality of
the care patient receives. Notification of the grievance process includes: who to contact to file a grievance, and that
patient will be provided with a written notice of the grievance determination that contains the name of the contact
person, the steps taken on patient’s behalf to investigate the grievance, the results of the grievance and the
grievance completion date.

14. Change physicians if desired, either within the or another physician of the patient’s choice.

15. Full consideration of privacy concerning the medical care program. Case discussion, consultation, examination and
treatment are confidential and should be conducted discreetly. The patient has the right to be advised as to the
reason for the presence of any individual involved in the patient’s healthcare.

16. Confidential treatment of all communications and records pertaining to patient’s care and visit at the surgery
center. The patient’s written permission shall be obtained before medical records can be made available to anyone
not directly concerned with patient’s care.

17. Full disclosure of the privacy policy.

18. Access information contained in your medical records within a reasonable time frame in accordance with
state/federal laws and regulations.

19. Reasonable responses to any reasonable requests made for service.

20. Leave the even against the advice of the attending physician.

21. Reasonable continuity of care and to know in advance the time and location of appointment as well as the
physician providing the care.

22. Be advised if physician/ proposes to engage in or perform human experimentation affecting the care or treatment.
The patient has the right to refuse to participate in such research projects or clinical trials.

23. Be informed by the attending physician or designee of the continuing health care requirements following discharge.

24. Obtain information before scheduled surgery about payment requirements of the bill, regardless of source of
payment.

25. Examine and receive an explanation of the bill regardless of source of payment.

26. If eligible for Medicare, to know upon request and in advance of treatment whether a healthcare provider or facility
accepts the Medicare assignment rate.

27. Expect reasonable safety insofar as the surgery center’s practice and environment are concerned.

28. Have all patients’ rights apply to the person who may have legal responsibility to make decisions regarding medical
care on behalf of the patient.

29. A list of these patient’s rights, which shall be posted within the surgery center so that such rights may be read by
all patients.

30. Receive appropriate knowledge regarding absence of malpractice insurance.

31. Receive appropriate information regarding provider credentialing.

32. Please be advised that the physicians who operate at Marietta Eye Surgery own an interest in . You are entitled to
obtain the services for which you have been referred to at the location of your choice. Alternative sources of the
services for which you have been referred to this entity are available in the community. Please ask us for a list of
facilities.

All personnel, medical staff members and contracted agency personnel performing patient care activities shall
observe these patients’ rights.

PATIENT RESPONSIBILITIES

The care a patient receives depends partially on the patient himself. Therefore, in addition to these rights, a patient has certain
responsibilities as well. These responsibilities should be presented to the patient in the spirit of mutual trust and respect:

1. Provide accurate and complete information about present complaint, past illnesses, hospitalizations and other matters
related to your health status.
2. Make it known whether course of treatment and what is expected of the patient is clearly understood.
3. Follow the treatment plan established by the physician, including the instructions of nurses and other health professionals
as they carry out the physician’s orders.
4. Keep appointments and notify the surgery center or physician when unable to keep an appointment.
5. Accept responsibility for any actions resulting from the refusal to follow treatment or physician’s orders.
6. Accept and ensure that the financial obligations of care are fulfilled as promptly as possible.
7. Follow polices and procedures.
8. Be considerate of the rights of other patients and personnel.
9. Be respectful of personal property and that of other persons in the surgery center.

Marietta Eye Clinic Strives to provide excellent patient care and service. If you should have a concern or complaint, please feel free to discuss
this with us. You may also contact:

Marietta Eye Surgery
895 Canton Road, Bldg. 200, Suite 300
Marietta, GA 30060
Phone: 678-784-0230
After Hours: 770-427-8111
www.mariettaeye.com

Department of Community Health-HFRD
Peachtree Street, NW, 31th Floor Ste. 447
Atlanta Georgia 30303-3142
404-657-5726/ 5728 or 1800-878-6442

Composite State Board of Medical Examiners
2 Peachtree Street, NW, 10th Floor
Atlanta Georgia 30303-3465
404-656-3913

Ombudsman’s
1-800-MEDICARE

https://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive
the information and help you need to understand your Medicare options and to apply your
Medicare rights and productions.

Thank you for allowing us to care for you.
Management and Staff of Marietta Eye Surgery

Patients Rights and Responsibilities

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Patients Rights and Responsibilities

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