Patient's Statement of Rights

Please review and attach to my chart.

            In this era of health care reform and rapidly changing paradigms many patients feel as though they are on the losing end of a quickly shortening stick.  Every time you go to a physician’s office or hospital you are bombarded with all sorts of forms to sign with all sorts of rules and regulations.  Who on earth can know what it all means?  It seems that everyone is telling patients what they can and cannot do; their physician’s office, hospitals, pharmacies, insurance companies and then government is telling everyone what can and cannot be done.  Is anyone actually looking after the patient?  Sadly, it seems no.  In light of these realities, here are some patient responses to all of this.  These are the things that I the patient, will and will not do or permit:

• When I call to make an appointment with my doctor, I want to see my doctor.  Not some other doctor or physician’s assistant or nurse practitioner; unless I specifically request or agree to that.
•  I will not be financially responsible for any charges or fees not covered by my insurance for any tests, procedures, consultations or lab unless those charges are specifically discussed with me prior to any of them actually being incurred.  After the charges are discussed, I will then decide whether to proceed or not and will inquire as to alternatives or if they can be done cheaper elsewhere.  Of course, this applies to routine situations, not dire emergencies.  It would be wise and helpful for you to post your routine fees and charges on your website and on a large sign in your waiting room.
•  I will not answer any questions about or provide any social or behavioral information, except things I may relate to my physician in private and confidence directly.  I do not give permission for any such information to be transmitted in any form to anyone or any private or governmental agency (local, state or federal) other than my physician.
•  I do not give my permission for any information of any sort to be transmitted to any private or governmental agency (local, state or federal) other than my insurance company.
•  I do not give my permission for any information to be stored off-site of my physician’s physical office.
•  I do not use my social security number as a personal medical identification number.  Please use an alternative number such as my employee ID number from my employer who provides my health insurance.  I will not provide my social security to anyone and do not give my permission for you to obtain it by any means or from any source and do not give my permission for you to retain and/or store it.

Thank you!

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Signed                                                                                                              Date (in effect until further                                                                                                                                         notice)

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Printed Name                                                                                                  Date of Birth