Disclosures for Patients

⮚ Have information about patient rights made available to you.
⮚ Be treated in a dignified and respectful manner that supports your dignity.
⮚ Care that respects your cultural and personal values, beliefs, and preferences.
⮚ Care that respects your right to personal privacy. This right may be limited in situations where
you must be continuously observed.
⮚ Expect us to protect the privacy and security of your health information.

⮚ Be allowed to access, request amendment to, and obtain information on disclosures of your health
information, per law and regulation.
⮚ Receive care in a safe setting.
⮚ Prohibit discrimination based on age, race, ethnicity, religion, culture, language, physical or
mental disability, socioeconomic status, sex, sexual orientation, and gender identity or
expression.

⮚ Care that respects your right to and need for effective communication.
⮚ Be provided with information in a manner tailored to age, language, and ability to
understand.
⮚ Be provided with interpreting and translation services, as necessary.
⮚ Receive communication in a manner that meets your needs for vision, speech, hearing, or cognitive
impairments.

⮚ Be provided (you or the surrogate decision-maker) with verbal and written notices of the
patient’s rights before the start of the procedure in a language and manner that you or the
surrogate decision-maker understands.
⮚ Have a copy of patient’s rights posted in a location where it is likely to be seen.
⮚ Provide you or your representative with a written notice, before the start of the procedure, that
the organization has physician-owners or physicians with a financial interest including a list of
these physicians.

⮚ Provide you or your surrogate decision-maker with the outcomes of care, treatment, or services that you need in order to participate in current and future health care decisions, and unanticipated outcomes of your care, treatment, or services that are sentinel events.
⮚ Receive informed consent. The discussion encompasses the proposed care, treatment or services, potential benefits, risks, and side effects of the proposed care, treatment, or services, the likelihood of achieving your goals, any potential problems that might occur during recuperation, reasonable alternatives to the proposed care, treatment, or services including risks, benefits, and side effects related to the alternatives, and the risks related to not receiving the proposed care, treatment, or services.

⮚ Obtain informed consent in advance when we make and use recordings, films, or other images for internal use other than the identification, diagnosis, or treatment (for example performance improvement and education).
⮚ Receive informed consent before a treatment or procedure is performed.
⮚ Be provided with information to help you determine whether to description of the procedures to be followed, a statement of the potential benefits, risks, discomforts and side effects, and alternative care, treatment, or services available that might prove advantageous.

⮚ Understand that refusing to participate in research, investigation, or clinical trials or
discontinuing participation at any time will not jeopardize your access to care, treatment, or
services unrelated to the research.
⮚ Know we will not carry out any Do Not Resuscitate order or other advance directive. We will
always try to revive you and transfer you to a hospital if you have a health emergency. Before the
start of the procedure, you or the surrogate decision-maker are provided with written information
concerning its policies on advance directives, including a description of applicable state health
and safety laws and, if requested, official state advance directive forms.
⮚ Be provided with possible sources of help in formulating advance directives, upon
request.

⮚ Be provided with the name of the physician or other practitioner who has primary responsibility
for your care, treatment, or services, and the name of the physician(s) or other licensed
practitioner(s) who will provide your care, treatment, or service.
⮚ Have the person appointed under State law to act on your behalf and exercise any of the rights
afforded you if adjudged incompetent under applicable State laws by a court of proper jurisdiction.
⮚ Freedom from neglect; exploitation; and verbal, mental, physical, and sexual abuse.

⮚ An evaluation of all allegations, observations, and suspected cases of neglect, exploitation, and
abuse.
⮚ Have allegations, observations, and suspected cases of neglect, exploitation, and abuse reported
to appropriate authorities based on its evaluation of the suspected events.
⮚ Freedom from all forms of abuse and harassment.
⮚ A complaint resolution process that informs you and your family about it.
⮚ Review and, when possible, resolve the complaints from you and your family.
⮚ Exercise your rights without being subject to coercion, discrimination, reprisal, or
interruption of care that could adversely affect you.

⮚ Voice grievances regarding treatment or care that are (or fail to be) furnished.
⮚ Have all allegations, violations, or grievances related to, but not limited to, mistreatment,
neglect, or verbal, mental, sexual, or physical abuse, immediately reported to a person in
authority.
⮚ Have all alleged violations or grievances related to, but not limited to, mistreatment, neglect,
or verbal, mental, sexual, or physical abuse, fully documented.
⮚ Have substantiated allegations related to, but not limited to, mistreatment, neglect, or verbal,
mental, sexual, or physical abuse, reported to the state authority or the local authority, or both.
⮚ Provided with a specified time frame for review of the grievance and the provision of a
response.

⮚ Have an investigation of all grievances made by you or your representative regarding treatment
or care that is (or fails to be) furnished.
⮚ Have the grievance addressed and be provided with a written notice of its decision. The decision
contains the name of the surgery center contact person, the steps taken to investigate the
grievance, the results of the grievance process, and the date grievance process was completed.

TO REPORT A COMPLAINT:
Indiana State Department of Health Care Facility Complaint Program

2 North Meridian Street, 4B, Indianapolis, IN 46204
Toll-free: 1-800-246-8909
Voicemail: (317) 233-5359
Email: complaints@isdh.in.gov

FOR MEDICARE BENEFICIARIES:

Information is available to you about your options, rights and protections under Medicare. The Medicare Beneficiary Ombudsman can help you with Medicare-related complaints, grievances and information requests.
Toll-free: 1-800-Medicare (1-800-633-4227) TTY: 1-877-486-2048
Online: www.medicare.gov

TO FILE A CIVEL RIGHTS COMPLAINT:

Centralized Case Management Operations
U.S. Department of Health and Human Services 200 Independence Avenue, S.W.
Room 509F HHH Bldg. Washington, D.C. 20201
Toll-free: 1-800-368-1019
TTD: 1-800-537-7697 / Fax: (202) 619-3818
Email: OCRComplaint@hhs.gov Online:
https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

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Advance Directives

Definition of Advance Directive – A general term that describes two kinds of legal documents, living wills and medical powers of attorney. These documents allow a person to give instructions about future medical care should he or she be unable to participate in medical decisions due to serious illness or incapacity. Each state regulates the use of advance directives differently.

• Indiana Do Not Resuscitate (DNR)
• Indiana Life-Prolonging Procedures Declaration
• Indiana Living Will Declaration
• Indiana Physician Orders for Scope of Treatment (Post)

In the event a patient appears at the surgery center with an advanced directive or living will, the medical director or the ASC director will be notified.

 ASC Surgical Ventures, Inc., The Surgery Center of Granger and OSMC Outpatient Surgery Center in Elkhart will not follow your Do Not Resuscitate (DNR) order or other advanced directives while you are a patient here. You will be treated if a complication occurs. ASC Surgical Ventures, Inc. will respect your choice of a person to receive information and make decisions for you if you cannot.