Patient Day of Surgery Package of Forms. Includes: Patient Rights & Responsibilities. Statement of Limitation Regarding Advance Directives
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1 Patient Day of Surgery Package of Forms Includes: Patient Rights & Responsibilities Statement of Limitation Regarding Advance Directives Patient Medication History Acknowledgement of Requirement for Responsible Adult to Remain on Premises Patient Communication Preferences Regarding PHI Patient Health History
2 Patient Rights & Responsibilities Patients Have the Right to: Receive access to equal medical treatment and accommodations regardless of race, creed, sex, national origin, religion or sources of payment for care. Be fully informed and have complete information, to the extent known by the physician, regarding diagnosis, treatment, procedure and prognosis, as well as the risks and side effects associated with treatment and procedure prior to the procedure. Exercise his or her rights without being subjected to discrimination or reprisal. Voice grievances regarding treatment or care that is (or fails to be) furnished. Personal privacy. Receive care in a safe setting. Be free from all forms of abuse or harassment. Receive the care necessary to regain or maintain your maximum state of health and if necessary, cope with death. Expect personnel who care for you to be friendly, considerate, respectful, and qualified through education and experience, as well as perform the services for which they are responsible with the highest quality of services. Be fully informed of the scope of services available at the Center, provisions for after-hours care and related fees for services rendered. Be a participant in decisions regarding the intensity and scope of treatment. If you are unable to participate in those decisions, the patient s rights shall be exercised by your designated representative or other legally designated person. Make informed decisions regarding your care. Refuse treatment to the extent permitted by law and be informed of the medical consequences of such refusal. The patient accepts responsibility for his or her actions including refusal of treatment or not following the instructions of the physician or Center. Approve or refuse the release of medical records to any individual outside the Center, or as required by law or third party payment contract. Express grievances/complaints and suggestions at any time. Access to and/or copies of your medical records. Be informed as to the Center s policy regarding Advance Directives/Living Will/Power of Attorney. Express those spiritual beliefs and cultural practices that do not harm or interfere with the planned course of medical therapy for the patient. Expect the Center to agree to comply with Federal Civil Rights Laws to provide interpretation for individuals who are not proficient in English. Have an assessment and regular assessment of pain. Education of you and your family, when appropriate, regarding your roles in managing your pain. To change providers if other qualified providers are available. If a patient is adjudged incompetent under applicable state health and safety laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under state law to act on the patient s behalf. If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state laws may exercise the patient s rights to the extent allowed by state law. Patients Responsibilities: Bring health insurance card(s) Bring government issued photo identification Bring form of payment (if applicable) Be certain to bring documentation of Guardianship or Power of Attorney, POA (if applicable) Be considerate of the rights of other patients and personnel and assist in the control of noise, number of visitors, eating and other distractions. Respect the property of others and the Center. Report whether you clearly understands the planned course of treatment and what is expected of you. Keep appointments and, when unable to do so for any reason, notify the Center and physician. Provide caregivers with the most accurate and complete information regarding present complaints, past illnesses and hospitalizations, and medications.
3 Report unexpected changes in the your condition, or any other health matters. Observe prescribed rules of the Center during your stay and treatment and, if instructions are not followed, forfeit the right to care at the Center. Promptly fulfill your financial obligations to the Center. Identify any patient safety concerns. Advance Directives Notification In the State of Arizona, all patients have the right to participate in their own health care decisions and to make Advance Directives or to execute Power of Attorney that authorize others to make decisions on their behalf based on the patient s expressed wishes when the patient is unable to make decisions or unable to communicate decisions. Surgery Center of Gilbert respects and upholds those rights. Arizona State Law (CFR Conditions for Coverage) permits ambulatory surgery centers to decline to implement certain elements of your Advance Directives based on our conscience and commitment to patient care. Unlike in an acute care hospital setting, the Surgery Center of Gilbert does not routinely perform high risk procedures. While no surgery is without risk, most procedures performed in this Center are considered to be of minimal risk. You will discuss the specifics of your procedure with your physician who can answer your questions as to its risks, your expected recovery, and care after your surgery. Therefore, it is our policy, regardless of the contents of any Advance Directives or instructions from a health care surrogate or attorney-in-fact, that if an adverse event occurs during the your treatment at this Center, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. At the acute care hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directives, or health care Power of Attorney. Your agreement with this Center s policy will not revoke or invalidate any current health care directive or health care power of attorney. If you wish to complete an Advance Directive, copies of the official state forms are available at our Center. If you do not agree with this Center s policy, we will be pleased to assist you in rescheduling your procedure. Disclosure of Ownership Surgery Center of Gilbert is proud to have a number of quality physicians invested in our Center. Their investment enables them to have a voice in the development and administration of policies for our Center. This involvement helps to ensure the highest quality of surgical care for our patients. Your physician, does /does not (circle as appropriate) have a financial interest in this Center. Responsible Party You must be accompanied by a responsible adult to provide transportation home after discharge from the Center and stay with you for the first 24 hours following your procedure. This individual must be present at the Center at all times. The responsible party for children under 18 must be a parent or guardian. By signing this document, I acknowledge that I have received, read and understood this information prior to my surgery/procedure. Patient / Patient Representative Signature Date Patient Complaint or Grievance To report a complaint or grievance, you can contact the Center Administrator by phone or mail: Surgery Center of Gilbert, 6003 E. Baseline Rd., Mesa, AZ Complaints and grievances may also be filed through: Arizona Department of Health Services, Division of Licensing Services, 150 N. 18 th Ave., Suite 450, Phoenix, AZ State of Arizona, CMS Regional Office, DHHS/CMS/DSC/CLIA, 90 7 th St., Suite (SW), San Francisco, CA , Accreditation Association for Ambulatory Health Care, 5250 Old Orchard Rd., Suite 200, Skokie, IL Medicare beneficiaries may receive information regarding their options under Medicare and their rights and protections by visiting the Office of the Medicare Beneficiary Ombudsman online at
4 Statement of Limitation Regarding Advance Directives Note a revocation of advance directives or medical power of attorney All patients have the right to participate in their own health care decisions and to make advance directives, or to execute power of attorney that authorize others to make decisions on their behalf based on the patient s expressed wishes when the patient is unable to make decisions or unable to communicate decisions. This Surgery Center respects and upholds those rights. However, unlike an acute care hospital setting, the Surgery Center does not routinely perform high-risk procedures. Most procedures performed in this facility are considered to be of minimal risk. Of course, no surgery is without risk. You will discuss the specifics of your procedure with your physician who can answer your questions as to your risks, expected recover and care after your surgery. Therefore, it is our policy, regardless of the contents of any advance directives or instructions from a health care surrogate or attorney in fact, that if an adverse event occurs during your treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. At the acute care hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, advance directives or health care power of attorney. Your agreement with this policy by your signature below does not revoke or invalidate any current health care directive or health care power of attorney. If you do not agree to this policy, we will be pleased to assist you in rescheduling the procedure. Please check the appropriate box to answer the following question: Have you executed an advance directive, a living will, or a power of attorney that authorizes someone to make health care decisions for you? *YES. I have an advance directive, living will or health care power of attorney and have furnished a copy to the Surgery Center of Gilbert. YES. I have an advance directive, living will or health care power of attorney but HAVE NOT furnished a copy to the Surgery Center of Gilbert. NO. I do not have an advance directive, living will or health care power of attorney. I would like to receive information on advance directives. * If you checked the first YES box above, please provide us with a copy of that document to place in your medical record. By signing this document, I acknowledge that I have read and understand its contents and agree to the policy as described. If I have indicated I would like to receive additional information, I acknowledge receipt of that information. By: Patient Signature Patient Last Name: Patient First Name: Date: If consent to the procedure is provided by anyone other than the patient, this form must be signed below by the person providing consent or authorization. I acknowledge that I have read and understand the policy and contents, and agree to the policy as described. By: Signature Print Name Relationship to Patient: Court Appointed Guardian Attorney in Fact Health Care Surrogate Other
5 Patient Medication History Allergies including tape, Betadine, medication, food and environmental All Prescription Drugs and Over-the-Counter Medications Drug Name & Dose Frequency Reason for Medication Dietary Supplements, Vitamins & Herbal Medications Drug Name & Dose Frequency Reason for Medication Discharge Medication Doctor / Nurse Use Only (this is not a prescription) Drug Name & Dose Frequency Reason for Medication Follow the guidance of your physician regarding resuming your pre-operative medications. Further information regarding medication administration, side effects and/or adverse reactions will be provided by your physician or dispensing pharmacy. These are a list of my current medications. Patient Signature and Date Patient Label PACU / Nurse Discharge Signature and Date
6 Acknowledgement of Requirement for Responsible Adult to Remain on Premises Patient Name: I acknowledge that as the responsible adult providing transportation after discharge from the Surgery Center of Gilbert, I have been advised to remain on premises at the Surgery Center. I will remain on the premises until the patient I am providing transportation has been discharged. Printed Name of Responsible Adult Relationship to Patient Responsible Adult Cell Phone Number Signature Date Please provide the name and number of the person that will be monitoring you for the 24 hours required after discharge. Same as above Name Phone Number If you and your responsible adult will be traveling using an outside transportation company, please provide their name and number below: Name Phone Number
7 Patient Communication Preferences Regarding PHI Telephone Communication Preferences: Home Phone Work Phone Mobile Phone Other Communication Preferences: Address Place Patient Identification Label Here In order to best serve our patients and communicate regarding their services and financial obligations we will use all methods of communication provided to expedite those needs. By providing the information above I agree that Surgery Center of Gilbert or one of its legal agents may use the telephone numbers provided to send me a text notification, call using a pre-recorded/artificial voice message through the use of an automated dialing service, or leave a voice message on an answering device. If an address has been provided, the Surgery Center or one of its legal agents may contact me with an notification regarding my care, surgery center services or my financial obligation. Mail Communication Preferences May we send mail to your home address? If no, please print an alternative mailing address: Other than you, your insurance company and health care providers involved in your care, who can we talk with about your health care information? Check all that apply: Name Spouse Caretaker Child Parent Other Telephone I acknowledge that I have been given the opportunity to request restrictions on use and/or disclosure of my protected health information. I acknowledge that I have been given the opportunity to request alternative means of communication of my protected health information. Patient or Personal Representative Signature Date Printed Name Relationship to Patient
8 Patient Health History Name All allergies (including tape, Betadine, latex, food, medications and environmental). Reactions? Previous Surgeries: Any problems with anesthesia for you or your family? Have you or anyone in your family been diagnoses with MRSA, VRE or C.Diff? No Yes. Date & treatment Please check all that apply to the patient only: For Children Only Reactive Airway Disease Immunizations current Y / N Chrosomal Disorder Loose Teeth Full term / Premature birth Autism Downs Syndrome Respiratory Pneumonia/ Valley fever/ TB Chronic or frequent cough Sleep Apnea/ CPAP machine Shortness of breath/ Oxygen use liters COPD - Bronchitis/ Asthma/ Emphysema Cardiovascular Pacemaker/ Defibrillator Chest pain / Angina Irregular heart rate Swelling of hands, feet, or ankles Rheumatic Fever High blood pressure Heart Murmur, Mitral valve prolapse (MVP) Heart Attack / Congestive Heart Failure Other: Endo Diabetes - diet/meds/insulin controlled Thyroid disease Skeletal Back or neck problems, fractures Arthritis / Rheumatism Neuro Fainting spells / seizures Tremors / Restless Leg Syndrome Weakness or paralysis of extremity / Stroke Numbness or tingling of extremity Anxiety/ Depression Often or severe headache / Migraines Memory loss/alzheimer s disease/dementia Parkinson s Disease Other Glaucoma Alcohol use, how often Smoking, how much/how long? Street drugs, what & how often? GI / GU Liver or gallbladder problems Esophagus or colon problems Jaundice / Hepatitis Hiatal hernia / Acid reflux Kidney / Bladder / Prostrate problems Other Skin Lesions / cancer / bruises Rashes / hives / eczema / psoriasis Reproductive Pre / post menopausal Date of last menstrual period Breast cancer / IIV or B/P restrictions Pregnant or breastfeeding? Hemo Anemia / bleeding tendencies / blood transfusions Phlebitis / blood clots Blood diseases / HIV Prosthesis / Joint Replacement Dentures / partial plates, upper or lower Hearing aids, right or left Glasses or contacts Metal implants, where? Notes Patient signature: History is correct to the best of my knowledge No changes in medical history History reviewed / RN signature:
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