You Have a Right: View in Spanish To know the name of the physician primarily responsible for your care and the identity of all individuals providing service to you. To care that is considerate and respectful of your personal values and beliefs. To receive from your physician, in language you can understand, your diagnosis, recommended treatment and related risks, and the prognosis of your illness. When it is determined by your physician that it is not medically advisable to give such information to you, the information should be made available to a designated decision maker, or other appropriate person. To talk freely with your physician and other care providers, and participate in decisions regarding your care. To know the reason why you are given various tests or treatments and who is doing the test/treatment. To change your mind about any procedure for which you have given your consent provided that a change of mind is made known to your physician before you have been medicated. To refuse to sign a consent form if you do not feel that everything has been satisfactorily explained to you or to cross out any part of the consent form that you do not want applied to your care. To refuse treatment to the extent permitted by law and to be informed of the medical consequences of this action. To designate those whom visit you and to limit those persons who visit you from outside the Hospital and are not involved in your general care and welfare, including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. To security and personal privacy. To confidentiality of information. To have your medical record read only by individuals directly involved in your treatment or the monitoring of its quality, and by other individuals only upon your written authorization or that of your legally authorized representative. To request a consultation from another or additional physician(s). To change physicians/change hospitals. To examine your Hospital bill and receive an explanation of it. To refuse to participate in medical training programs and research projects. To obtain Hospital care without charge if you are unable to pay and qualify for the Financial Assistance Program. If you believe you may be eligible for such assistance, contact the Financial Assistance Counselor at Sheltering Arms Institute. To impartial access to the medical resources for your care without regard to age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression, or source of payment. To expect that all Sheltering Arms Institute employees adhere to standards of conduct and an ethical code based on the organization’s mission, vision and values. To ask for assistance for consideration of an ethical issue related to your care. To access Protective Services. To pastoral counseling. To obtain information or counseling on organ and tissue donation. To the assessment and management of pain as well as to be educated regarding effective pain management. To be informed of any unintended consequences of care, treatment or services. To be protected from neglect, exploitation, and abuse while receiving care, treatment and services. To be treated in a dignified and respectful manner in an environment that promotes a positive self-image. To have complaints reviewed by the hospital. If at any point during your stay or treatment at Sheltering Arms Institute you are dissatisfied with the services or treatment you have received, or feel as though your patient rights have not been honored you are encouraged to request to speak with the supervisor and/or administration. You may also contact our Quality Management Department. If you still feel your concerns have not been addressed appropriately, you may ask for assistance in the resolution of a complaint or grievance by contacting the Office of Licensure and Certification of the Virginia Department of Health at toll-free: 1-800-955-1819 or Metro Richmond area: 804-367-2106. To file a written complaint by US Mail: Office of Licensure and Certification Virginia Department of Health 9960 Mayland Dr., Suite 401 Henrico, VA 23233-1463 OR The Office of Quality and Safety The Joint Commission One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181 Email: email@example.com Fax: 630-792-5636 Medicare Beneficiaries may contact: LIVANTA LLC BFCC QIO 10820 Guilford Road, Suite 202 Annapolis Junction, MD 20701-1105 Attention: Beneficiary Complaints Toll-free: 1-888-396-4646 TTY: 1-888-985-2660 Fax: 1-855-236-2423 You Have a Responsibility: 1. To know and follow instructions, policies, rules and regulations in place to support quality of care for patients and a safe environment for all individuals. 2. To cooperate and to follow the care prescribed for you. You are responsible for your actions if you refuse treatment or do not follow the physician’s instructions. 3. To notify your physician or nurse if you do not understand and need further explanation concerning your diagnosis, treatment and prognosis. 4. To let us know if you feel you are receiving too many visitors from outside the Hospital. 5. To respect the privacy and rights of other patients and Sheltering Arms Institute personnel. 6. For the financial obligations of your health care. 7. To provide, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health 8. For reporting perceived risks in your care and unexpected changes in your condition to your physician or nurse. 9. To support mutual consideration and respect by maintaining civil language and conduct with interactions with staff and licensed independent practitioners. Disclosure Statement Sheltering Arms Institute (“SAI”) is jointly owned by Sheltering Arms Physical Rehabilitation Centers(“SAPRC”) and Virginia Commonwealth University Health System Authority (“VCUHS”) and clinicians affiliated with SAPRC or VCUHS may provide some services at SAI. Based on their medical judgment, SAI staff or clinicians may refer you to SAPRC or VCUHS for additional health care services outside of SAI. You acknowledge that you have been made aware of the ownership of SAI by VCUHS and SAPRC and that you have the right to choose any provider on the medical staff of SAI or to seek services outside of SAI.