• 01.  The patient has the right to understand and use these rights. If for any reason you do not understand or you need help, the Eastern Orange ASC MUST provide assistance, including an interpreter.
• 02.  The patient has the right to receive treatment without discrimination as to race, color, religion, sex, national origin, disability sexual orientation or source of payment.
• 03.  The patient has the right to receive considerate, dignified and respectful care in a clean and safe environment free of unnecessary restraints.
• 04.  The patient shall be informed verbally and in writing of his/her rights in advance of the date of the procedure, in terms that the patient can understand. A signature acknowledging receipt of verbal and written notification of these rights in advance of the day of the procedure will be obtained by the patient and or legal guardian and placed in the patient’s chart as part of the permanent medical record.
• 05.  The patient has the right to receive emergency care if you need it, including information on the facilities provisions for emergency and after hours and emergency care.
• 06.  The patient has the right to be informed of the name and position of the doctor who will be in charge of your care in the Eastern Orange ASC.
• 07.  The patient has the right to know the names, positions and functions of any Eastern Orange ASC staff involved in your care and refuse their treatment, examination or observation.
• 08.  The patient has the right to a no smoking room.
• 09.  The patient has the right to receive complete information about your diagnosis, treatment and prognosis. When it is medically inadvisable to give such information to a patient, the information is provided to a person designated by the patient or to a legally authorized person.
• 10.  The patient has the right to receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.
• 11.  The patient has the right to receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet “Do Not Resuscitate Orders — A Guide for Patients and Families.”
• 12.  The patient has the right to refuse treatment and be told what effect this may have on your health.
• 13.  The patient has the right to refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation.
• 14.  The patient has the right to privacy while in the Eastern Orange ASC and confidentiality of all information and records regarding your care. Patients are given the opportunity to approve and refuse their release.
• 15.  The patient will be informed of the fees and related charges, including the payment, fee, deposit, and refund policy of the Surgery Center and any charges not covered by third-party payers or by the Surgery Center’s basic rate.
• 16.  The patient has the right to change their provider if other qualified providers are available.
• 17.  The patient has the right to be informed about procedures for expressing suggestions, including complaints and grievances, including those regulated by state and federal regulations.
• 18.  The patient has the right not to be misled by marketing or advertising regarding the competence and capabilities of the organization.
• 19.  The patient has the right to be provided with appropriate information regarding the absence of malpractice insurance coverage.
• 20.  The patient shall be informed verbally and by written notice in advance of the date of the procedure, of his/her physicians financial interest or ownership in the ASC; The signed copy of patient acknowledgement and notification of the physician financial interest or ownership will be placed in the patient’s chart as part of the permanent medical record.
• 21.  The patient shall be informed verbally and by written notice in advance of the date of the procedure, information on the ASC’s policy on advance directives, including a description of applicable NY health and safety laws and, if requested, official NY advance directive forms. The signed copy of patient acknowledgement and notification of the ASC policy on advance directives will be placed in the patient’s chart as part of the permanent medical record.
• 22.  The patient has the right to participate in all decisions about your treatment and discharge from the Eastern Orange ASC, except when such participation is contraindicated for medical reasons. The Eastern Orange ASC must provide you with a written discharge plan and written description of how you can appeal your discharge.
• 23.  The patient has the right to review his/her medical record without charge. Obtain a copy of your medical record for which the Eastern Orange ASC can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay.
• 24.  The patient has the right to receive an itemized bill and explanation of all charges.
• 25.  The patient has the right to complain without fears of reprisals about the care and services you are receiving and to have the Eastern Orange ASC respond to you and if you request it, a written response. If you are not satisfied with the Eastern Orange ASC’s response, you can complain to the New York State Health Department. The Eastern Orange ASC must provide you with the State Health Department telephone number.
• 26.  The patient has the right to authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.
• 27.  The patient has the right to make known his/her wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the Eastern Orange ASC. Public Health Law(PHL)2803 (1)(g)Patient’s Rights, 10NYCRR, 405.7,405.7(a)(1),405.7(c)
• 28.  The patient has the right to information regarding credentialing of Health Care Professionals at the Center.
• 29.  The patient has the right to refuse any treatment, except as otherwise provided by law.
• 30.  The patient has the right to receive care in a safe setting free from all forms of abuse and harassment.
• 31.  The patient will not be discriminated against because of age, race, religion, sex, nationality, or ability to pay, or deprived of any constitutional, civil, and/or legal rights solely because of receiving services from the facility.
• 32.  A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.
• 33.  A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
• 34.  A patient is responsible for following the treatment plan recommended by the health care provider.
• 35.  A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.
• 36.  A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions.
• 37.  A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled for any charges not covered by his/her insurance as promptly as possible.
• 38.  A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.
• 39.  A patient is responsible to provide complete and accurate information about his/her health, any medications, including herbals and over the counter supplements and any allergies or sensitivities.
• 40.  A patient is responsible to follow the treatment plan prescribed by his/her provider.
• 41.  A patient is responsible to inform his/her provider about any living will, medical power of attorney, or other directive that could affect his/her care.
• 42.  A patient is responsible to be respectful of all the health care providers and staff, as well as other patients.
• 43.  A patient is responsible to provide a responsible adult to transport hi/her home from the facility and remain with him/her for 24 hours if required by his/her provider.
• 44.  The patient will not be discriminated against because of age, race, religion, sex, nationality, or ability to pay, or deprived of any constitutional, civil, and/or legal rights solely because of receiving services from the facility.

The administrator will provide upon request to all patients and/or their families, the names, addresses, and telephone numbers of the following offices where complaints may be lodged:

The administrator shall also provide all patients and/or their families, upon request, the names, addresses and telephone numbers of offices where information concerning Medicare and Medicaid coverage may be obtained.

The Medicare Ombudsman is available to the public and ASC patients to get information about the Medicare and Medicaid programs, prescription drug coverage, and how to coordinate Medicare benefits with other health insurance programs. Information about filing a grievance or complaint can be obtained from their website, by mail or via phone.

CMS Contact Information:
Telephone: 1-800-633-4227 - 24 hours / 7 days including some federal holidays
TTY/TDD users can call 1-877-486-2048. This system is available 24 hours 7 days per week.

Mailing address:
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore MD 21244-1850

The website for the Medicare Ombudsman is: https://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html