As a patient in a Clinic in New York State, you have the right, consistent with law, to:

1. Receive services(s) without regard to age, race, color, sexual orientation, religion, marital status, sex, national origin or sponsor;
2. Be treated with consideration, respect and dignity including privacy in treatment;
3. Be informed of the services available at the center;
4. Be informed of the provisions for off-hour emergency coverage;
5. Be informed of the charges for services, eligibility for third-party reimbursements and, when applicable, the availability of free or reduced cost care;
6. Receive an itemized copy of his/her account statement, upon request;
7. Obtain from his/her health care practitioner, or the health care practitioner's delegate, complete and current information concerning his/her diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand;
8. Receive from his/her physician information necessary to give informed consent prior to the start of any nonemergency procedure or treatment or both. An informed consent shall include, as a minimum, the provision of information concerning the specific procedure or treatment or both, the reasonably foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision;
9. Refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of his/her action;
10. Refuse to participate in experimental research;
11. Voice grievances and recommend changes in policies and services to the center's staff, the operator and the New York State Department of Health without fear of reprisal;
12. Express complaints about the care and services provided and to have the center investigate such complaints. The center is responsible for providing the patient or his/her designee with a written response within 30 days if requested by the patient indicating the findings of the investigation. The center is also responsible for notifying the patient or his/her designee that if the patient is not satisfied by the center response, the patient may complain to the New York State Department of Health's Office of Health Systems Management;
1-800-804-5447
New York State Department of Health
Centralized Hospital Intake Program
Mailstop: CA/DCS
Empire State Plaza
Albany, NY 12237
13. Privacy and confidentiality of all information and records pertaining to the patient's treatment;
14. Approve or refuse the release or disclosure of the contents of his/her medical record to any health-care practitioner and/or health-care facility except as required by law or third-party payment contract;
15. Access to his/her medical record per Section 18 of the Public Health Law, and Subpart 50-3.
16. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors; and
17. Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the center.
18. To have competent, caring healthcare providers who act as your advocates
19. To know about any business relationships among the facility, healthcare providers, and others that might influence your care of treatment
20. To be informed of their right to change their provider if other qualified providers are available.
21. To be informed of the availability of free or reduced cost care through the center’s community outreach and free care initiative.
22. To be free from all forms of abuse and harassment

COMPLAINTS AND CONCERNS CAN BE EXPRESSED IN ANY OF THE FOLLOWING WAYS:

1. Call the new York State Department of Health complaint hotline at: 800-804-5447 or write to:
New York State Department of Health
Centralized Hospital Intake Program
Mailstop: CA/DCS
Empire State Plaza
Albany, NY 12237
2. Discuss with your physician
3. Discuss with the Center's Administrator at (718) 708-5777 or write to:
Empire State Ambulatory Surgery Center
3170 Webster Ave
Bronx, NY 10467
4. Call the Medicare Beneficiary Hotline at 1-800-MEDICARE (1-800-633-4227) or write to:
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850
5. Or contact the Medicare Ombudsman via the world wide web at:
   https://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

PATIENT RESPONSIBILITIES:

1. Patients are responsible for providing accurate and complete information regarding their health status, medical history, and current medications.
2. Patients are responsible for reporting any change in their condition during the present course of treatment and recovery.
3. Patients are responsible for participating in care decisions and for asking questions when they do not understand the information provided.
4. Patients have the responsibility to be considerate of others, including health care professionals and staff, as well as other patients, and to respect their rights, privacy, and property.
5. Patients are responsible for adhering to the plan of treatment by following instructions, participating in his/her care, keeping appointments, and cooperating with care providers who assist with carrying out the plan(s) of care.
6. Patients are responsible for providing a responsible adult to transport him/her home from the facility and remain with him/her for twenty-four (24) hours, if required by his/her provider.
7. Patients are responsible for recognizing the effect of lifestyle choices on their personal health.
8. Patients are responsible for providing complete and accurate third party payer information and meeting any outstanding financial obligations related to the services received. Collaboration and agreement of payment policies and fees for services will be documented.