Statement of Rights

Recovering from an injury or managing a chronic condition often requires more than just traditional medical care.

Statement of Rights and Responsibilities

Patients/Clients have the Right -

To be treated with dignity and respect
To fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment of care
To have the treatment and other patient information kept private. Only by law may records be released without patient permission.
To access care easily and in a timely fashion
To a candid discussion about all treatment choices, regardless of cost or coverage by their benefit plan. ● To share in developing the treatment plan.
To the delivery of services in a culturally competent manner.
To information about the organization, its providers, services and role in the treatment process ● To information about provider work history and training.
To information about clinical guidelines used in providing and managing their care.
To know about advocacy and community groups and prevention services.
To freely file a complaint, grievance, or appeal and to learn how to do so
To know about laws which relate to their Rights and Responsibilities.
To know about their Rights and Responsibilities in the treatment process, and to make recommendations regarding the organizations Rights and Responsibilities policy.

Patients/Clients have the Responsibility:

To treat those giving them care with dignity and respect.
To give providers the information needed in order to provide the best possible care.
To ask providers questions about their care.
To help develop and follow the agreed-upon treatment plan for their care, including the agreed-upon medication plan.
To inform the provider if the treatment plan no longer works for them.
To inform the provider of any medication changes, including medications given to them by others. ● To keep the scheduled appointments or notify as soon as possible if they need to reschedule or cancel the visit(s).
To inform the provider of any changes in insurance coverage.
To inform the provider of any difficulty with paying fees.
Not to take actions which could harm others.
To report fraud and abuse.
To openly report concerns for quality of care.
To inform provider of any changes to their name and contact information (name, address, phone, etc) Patients/Clients have the Right and the Responsibility to understand and develop plans and goals to improve their health.

I have read and understood Rights and Responsibilities.

First Name

Date / Time

Patient Signature

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Witness / Staff Member Signature

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INNERVE8 Medical 2034 Eisenhower Avenue Suite 100, Alexandria VA 22314