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1. To be informed of the patient’s bill of rights, by being offered a written copy of this document and given a written or verbal explanation of your rights in terms you can understand. We will make efforts to have a written copy in the patient’s primary language or large print available upon request. If translation is unavailable, an interpreting service will be used.

2. To be informed of services available in this facility, of the names and professional status of the personnel providing and/or responsible for the patient’s care, and of fees and related charges, including the payment, fee deposit and refund policy of the facility and any charges for services not covered by sources of third-party payment or not covered by the facility’s basic rate.

3. To be informed if the facility has authorized other health care and educational institutions to participate in the patient’s treatment. The patient also shall have a right to know the identity and function of these institutions, and to refuse to allow their participation in the patient’s treatment.

4. To receive, in terms the patient understands, an explanation of his or her recommended treatment, risk(s) of the treatment, expected results and reasonable diagnostic alternatives. If the patient is not capable of understanding the information, the explanation shall be provided to his or her next of kin or guardian and documented in the patient’s medical record.

5. Except in an emergency, to be informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure.

6. To participate in the planning of your own care and treatment, and to refuse medication and treatment.

7. To be included in experimental research only when you give written consent to such participation, or when a guardian gives such consent in accordance with law, rule and regulation. You may refuse to participate in experimental research, including the investigation of new drugs and medical devices.

8. To be informed of the patient complaint process and voice grievances or recommend changes in policies and services to facility personnel, the governing authority, and/or outside representatives of the patient’s choice either individually or as a group, and free from restraint, interference, coercion, discrimination, or reprisal.

9. To be free from mental and physical abuse, neglect, exploitation, coercion, manipulation, sexual abuse and sexual assault and free from use of restraints unless they are authorized by a physician for a limited period of time to protect the patient or others from injury. Drugs and other medications shall not be used for discipline of patients or for convenience of facility personnel. Personal property of patients shall be preserved at all times while in custody of the Clinic.

10. To confidential treatment of information about the patient. Information in the patient’s medical record and financial record shall not be released to anyone outside the facility without the patient’s approval, unless another health care facility to which the patient was transferred requires the information, or unless the release of the information is required and permitted by law, a third-party payment contract, or a peer review, or unless the information is needed by the State Department of health for statutorily authorized purposes. The facility may release data about the patient for studies containing aggregated statistics when the patient’s identity is masked. The patient has the right, upon written request, to review his or her own medical record.

11. To be treated with courtesy, consideration, respect, and recognition of the patient’s dignity, individuality, and right to privacy, including, but not limited to, auditory and visual privacy. The patient’s privacy shall also be respected when facility personnel are discussing the patient.

12. To not be required to work for the facility unless the work is part of the patient’s treatment and is performed voluntarily by the patient. Such work shall be in accordance with local, State, and Federal laws and rules.

13. To exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, or any attendance at religious services, shall be imposed upon any patient.

14. To treatment and medical services without discrimination based on race, age, religion, national origin, sex, sexual preferences, handicap, diagnosis, ability to pay or deprived of any constitutional, civil and/or legal rights solely because of receiving services from the facility.

15. To consent to photographs before the patient is photographed, except that a patient may be photographed when admitted to an outpatient treatment center for identification and administrative purposes.

16. To receive a referral to another health care institution if the outpatient treatment center is not authorized or not able to provide physical health services or behavioral health services needed by the patient.

17. To refuse or withdraw consent for treatment before treatment is initiated.


The Patient Self Determination Act of 1990 (The PSDA) is a Federal law which imposes on the state and providers of health care such as hospitals, nursing homes, hospices, home health agencies, and prepaid health care organizations certain requirements concerning advance directives and an individual’s right under state law to make decisions concerning medical care.

Under the law, you have the right to make health care decisions for yourself. A patient must consent to any treatment or care received. Generally, if you are a competent adult, you can give this consent for yourself. For you to give this consent, you should be told what the recommended procedure is, why it is recommended, what risks are involved with the procedure, and what the alternatives are.

If you are not able to make your own health care decisions, your advance directives can be used. The PSDA defines an advance directive as a written instruction, such as an Individual Instruction or Power of Attorney for Health Care, recognized under State law and relating to the provisions of health care when the individual is incapacitated.

An Individual Instruction is a written directive concerning a health care decision.

Power of Attorney for Health Care (PAHC) is a document through which you designate someone as your agent to make health care decisions for you if you are unable to make such decisions. The PAHC comes into play when you cannot make a health care decision, either because of permanent or temporary illness or injury. The PAHC must specifically authorize your agent to make health care decisions for you and must contain the standard language set out in the law.

If you are unable to make a decision and have not given or prepared individual instructions or a PAHC, you may designate an adult of your choice, called a surrogate, to make health care decisions for you. If you do not appoint a surrogate, the members of your family may make decisions for you.

For more information on Health Care Decisions visit: http://www.hcdecisions.org

This webpage, hosted by the U.S. Living Will Registry, provides a state-by-state list, with links to state specific websites that provide free advance directive forms. https://uslwr.com/formslist.shtm

This webpage, provided by the American Bar Association provides a great tool kit, which contains a variety of self-help worksheets, suggestions, and resources. There are 10 tools in all, each clearly labeled and user- friendly. The tool kit does not create a formal advance directive for you. Instead, it helps you do the much harder job of discovering, clarifying, and communicating what is important to you in the face of serious illness.


All patients have the right to participate in their own health care decisions and to make Advance Directives or to execute Powers 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 Modern Vascular, respects and upholds those rights.

However, unlike in an acute care hospital setting, Modern Vascular, does not routinely perform “high risk” procedures. While no surgery is without risk, the procedures performed in this facility 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 risk, your expected recovery, and care after your surgery.

Therefore, it is our policy, regardless of the contents of any Advance Directive 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 treatments or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive, or health care power of Attorney. Your agreement with this facility’s policy will not revoke or invalidate any current health care directive or health care power of attorney.

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