BROOK PLAZA AMBULATORY SURGICAL CENTER
(1) Understand and use these rights. If for any reason you do not understand or you need help, you must be provided with assistance, including an interpreter. (2) Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation or source of payment. (3) Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. (4) Receive appropriate care. (5) Be informed of the name and position of the doctor who will be in charge of your care. (6) Know the names, positions and functions of any staff involved in your care and refuse their treatment, examination or observation. (7) A non smoking environment. (8) Receive complete information about your diagnosis, treatment and prognosis. (9) Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment. (10) Receive all the information you need regarding a do not resuscitate order. (11) Refuse treatment and be told what effect this may have on your health. (12) Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation.
(13) Privacy while in the facility and confidentiality of all information and records regarding your care. (14) Participate in all decisions about your treatment. (15) Review your medical record without charge. Ob- tain a copy of your medical record for which the facility can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay. (16) Receive an itemized bill and explanation of charges. (17) Complain without fear of reprisals about the care and services you are receiving and to have the facility respond to you and if you request it, a writ- ten response. If the patient is not satisfied by the Center’s response, the patient may complain to the New York State Department of Health’s Metropoli- tan Area Regional Office (MARO) at 800-804-5447. (18) Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors. (19) Know that your wishes regarding anatomical gifts can be documented on a health care proxy. (20) Call your State Medicare Quality Improvement Or- ganization (QIO) if you have a complaint about the quality of Medicare covered services. You can find the telephone number for your state’s Medicare QIO by visiting www.medicare.gov and selecting “Find Helpful Phone Numbers & Website.” You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Visit the Om- budsman’s Website at www.cms.hhs.gov/center/ ombudsman.asp.