Patient’s Rights & Notification of Physician Ownership

EVERY PATIENT HAS THE RIGHT TO BE TREATED AS AN INDIVIDUAL AND TO ACTIVELY PARTICIPATE IN AND MAKE INFORMED DECISION REGARDING HIS/HER CARE. THE FACILITY AND MEDICAL STAFF HAVE ADOPTED THE FOLLOWING PATIENT RIGHTS AND RESPONSIBILITIES, WHICH ARE COMMUNICATED TO EACH PATIENT OR THE PATIENT’S REPRESENTATIVE PRIOR TO THE PROCEDURE/SURGERY.

Patient’s Rights:

A patient, patient representative or surrogate has the right to: 

• Receive information about rights, patient conduct and responsibilities in a language and manner the patient, patient representative or surrogate can understand.
• Be treated with respect, consideration, and
• Be provided appropriate personal privacy.
• Have disclosures and records treated confidentially.
• Be a participant in decisions regarding the their healthcare.
• Receive care in a safe setting and be free from all forms of abuse, neglect, or harassment.
• Exercise his or her rights without being subject to discrimination or reprisal with impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical ability, or source of payment.
• Voice complaints or grievances, without reprisal.
• Complete information, to the extent known by the physician, regarding diagnosis, treatment, and prognosis, as well as alternative treatments or procedures and the possible risks and side effects associated with treatment.
• Refuse treatment to the extent permitted by law and be informed of the medical consequences of such a refusal. The patient accepts responsibility for his or her actions should he or she refuses treatment or does not follow the instructions of the physician.
• Have the right to change providers if other qualified providers are available.
• A prompt and reasonable response to questions and requests.
• Know what patient support services are available, including availability of an interpreter if a patient does not speak English.
• Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care and know, upon request and prior to treatment, whether the facility accepts the Medicare assignment rate.
• Receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have charges explained.
• Know the facility policy on advance directives and to formulate advance directives to appoint a surrogate to make healthcare decisions on his or her behalf to the extent permitted by law and provide a copy to the facility for placement in their medical record.
• Be informed of the names of the physicians who have ownership in the facility.
• Have properly credentialed ad qualified healthcare professionals providing patient care.
• Be fully informed about the treatment or procedure and the excepted outcome before it is performed.
• Have a person appointed under State law to act on the patient's behalf if the patient is adjudged incompetent under applicable State health and safety laws by a court of proper jurisdiction. If a State court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with State law may exercise the patient’s rights to the extent allowed by law.

A patient, patient representative or surrogate is responsible for:

• Providing a responsible person available to provide transportation home and stay with him/her for 24 hours, unless specifically exempted from this responsibility by his/her provider.
• Providing to the best of his or her knowledge, accurate and complete information about his/her health, present complaints, past illnesses, hospitalizations, any medications, including over-the-counter products and dietary supplement, any allergies or sensitivities, reactions and other matter relating to his or her health.
• Accept personal financial responsibility for any charges not covered by his/her insurance.
• Following the treatment plan recommended by his/her healthcare provider.
• Be respectful of all the healthcare providers and staff, as well as other patients.
• Providing a copy of information that you desire us to know about a durable power of attorney, healthcare surrogate, or other advance directive.
• His/her actions if he/she refuses treatment or does not follow the health care provider’s instructions.3
• Reporting unexpected changes in the patient's condition to the health care provider.
• Reporting to his/her health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
• Keeping scheduled appointments.

Medicaid Fraud:

To report suspected Medicaid fraud, please call AHCA Medicaid Program Integrity toll-free at (1-888-419-3456) or the Attorney General toll-free at (1-866-966-7226).

Abusive, Neglectful, or Exploitative Practices

To report abuse, neglect, or exploitation, please call the Florida Department of Children and Families toll-free (1-800-962-2873).

If you need an interpreter:

If you will need an interpreter, please let us know and one will be provided for you. If you have someone who can translate confidential, medical and financial information for you please make arrangements to have them accompany you on the day of your procedure.

Rights and Respect for Property and Person:

The patient has the right to: Exercise his or her rights without being subjected to discrimination or reprisal. Voice a grievance regarding treatment or care that is, or fails to be furnished. Be fully informed about a treatment or procedure and the expected outcome before it is performed.

Confidentiality of personal medical information.
Privacy and Safety: The patient has the right to: Personal privacy. Receive care in a safe setting. Be free from all forms of abuse or harassment.

Advance Directives:

You have the right to information regarding advance directives, this facility’s policy on advance directives, and information regarding state regulations concerning advance directives. Applicable state forms are available from the center and will be provided upon request.

When a person becomes unable to make decisions due to a physical or mental change or condition, they are considered incapacitated. To make sure that an incapacitated person’s decisions about health care will still be respected, the Florida legislature enacted legislation pertaining to health care advance directives (Chapter 765, Florida Statutes).

The law recognizes the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death. The state rules that address this include 58A-2.0232, 59A-3.254, 59A-4.106, 59A-8.0245, and 59A-12.013, Florida Administrative Code. and Florida statute Title XLIV, Chapter 765.

This ambulatory surgery center is not an acute care facility. Due to the nature of the procedures performed at this facility, it is this healthcare facility’s policy for all procedures and patients that in the event that a patient experiences a deterioration in his/her condition, we will always attempt to resuscitate a patient and transfer the patient to a hospital. We recognize each patient’s right to make informed decisions regarding his/her care. Therefore, any patient who desires to have their advance directives honored will be offered care at an alternate facility.

If you have executed advance directives and they have been provided to the surgery center, a copy of the advance directives will be sent to the hospital with the patient.

If you wish to complete an Advance Directive, copies of the official State forms are available at our facility.

Complaints/Grievances:

If you have a problem or complaint, please speak to one of our staff to address your concern. If necessary, your problem will be advanced to center management for resolution. You have the right to have your verbal or written grievances investigated and to receive written notification of actions taken.

The following are the names and or agencies you may contact:
ASC Director 863-343-8561
1470 N Florida Ave, Ste 120
Lakeland, FL 33805

You may contact the state to report a complaint: Florida Department of Health Ph: 850-245-4339 or TF: 1-888-419-3456

Consumer Services Unit http://www.doh.state.fl.us/mqa/enforcement/enforce_home.html
4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275

Medicare beneficiaries may also file a complaint with the Medicare Beneficiary Ombudsman at www.medicare.gov/Ombudsman/resources.asp
Medicare: www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227)

Office of the Inspector General:

http://oig.hhs.gov

Physician Financial Interest and Ownership:

The center is owned, in part, by the physicians. The physician(s) who referred you to this center and who will be performing your procedure(s) may have a financial and ownership interest. Patients have the right to be treated at another health care facility of their choice. We are making this disclosure in accordance with federal regulations.

The following physicians have a financial interest in this center:

• Sunil Gupta, MD
• Ketul Chauhan, MD
• Chetan Khamare, MD
• Vikas Soma, MD
• Iosif Kelesidis, MD
• Huy Khuu, MD