Welcome to Centro San Vicente.

Our goal is to provide quality health care to qualified persons in this community, regardless of their ability to pay. If the Center is enrolling new patients, you may be eligible to become our patient. As a patient, you have rights and responsibilities. The Center also has rights and responsibilities. We want you to understand these rights and responsibilities so you can help us provide better health care for you. Please read and sign this statement and ask us questions you might have.

Human Rights:

• You have a right to be treated with respect and dignity regardless of race, religion, sex, national origin, sexual orientation, political affiliation, disability or ability to pay for services.

Payment for Services:

• You are responsible for giving us accurate information about your present financial status and any changes in your financial status. We need this information to decide how much to charge you and/or so we can bill private insurance, Medicaid, Medicare, or other benefits for which you may be eligible. If your income is less than the federal poverty guidelines, you will be charged a discounted fee. A nominal fee will be collected at the time you check in prior to receiving services.
• You have a right to receive explanations of our bill. You must pay, or arrange to pay, all agreed fees for medical services with the exception of dental services, which are provided on a prepaid basis. If you cannot pay right away, please let us know so we can provide care for you now and work out a payment plan.
• Federal law prohibits us from denying you primary health care services, which are medically necessary, solely because you cannot pay for these services.

Privacy:

• You have a right to have your interviews, examinations, and treatment in privacy. Your medical records are also private. Only legally authorized persons may see your records unless you request in writing for us to show them to someone else. A complete discussion of your privacy rights is attached as “Notice of Client Privacy Rights.” By signing this document you are indicating that you have received this Notice. The Notice details the various rights granted to you by the Health Insurance Portability and Accountability Act.

Health Care:

• You are responsible for providing us complete and current information about your health or illness, so that we can give you proper health care.You have a right, and are encouraged, to participate in decisions about your treatment.
• You have a right to information and explanations in the language you normally speak and in words that you understand. You have a right to information about your health or illness, treatment plan (including risks) and expected outcome, if known, and information regarding advance Directives. If you do not wish to receive this information, or if it is not medically advisable to share that information with you, we will provide it to a legally authorized person.·
• You are responsible for appropriate use of our services, which includes following our staff’s instructions, making and keeping scheduled appointments, and requesting a “walk in” appointment only when you are ill. We may not be able to see you unless you have an appointment. If you cannot follow the staff’s instructions, please tell us so we can help you. You are responsible for notifying the clinic to cancel an appointment in advance so that the appointment can then be given to another client.
• If you are an adult, you have a right to refuse treatment to the extent permitted by law and to be informed of the risks of refusing such care.You are responsible for the outcome of refusing treatment.
• You have a right to health care and treatment that is reasonable for your condition and within our capability.
• You have a right to be transferred or referred to another facility for services that we cannot provide. But, we do not pay for services that you get somewhere else. The Center is not an emergency care facility.
• If you are in pain, you have a right to receive an appropriate assessment and management, as necessary.

Center Rules:

• You have a right to receive information on how to appropriately use the Center’s services. You are responsible for using the Center's services in an appropriate manner. If you have questions, please ask us.· You are responsible for the supervision of children you bring with you to the Center.
• You are responsible for their safety and the protection of clients and our property.
• You have a responsibility to keep your scheduled appointments. Missed scheduled appointments cause delay in treating other patients. If you do not keep scheduled appointments, the center reserves the right to determine whether you can continue as a patient of the center

Complaints:

• If you are not satisfied with our services, please tell us. We want suggestions so we can improve our services. We will tell you how to file a complaint. If you are not satisfied with how we handle your complaint, you may complain to the Board of Directors. The process for communicating complaints is delineated in the Patient Complaint Resolution Procedure.
• If you complain we will not punish you for filing a complaint and we will continue to provide you with good quality health care services

Termination:

• You have a right to advance notice, if we decide that we must stop treating you as a patient, that explains the reason for the decision and you will be given 30 days to find other health care services. We can decide to stop treating you immediately and without notice if you have created a threat to the safety of the staff and/or other clients. You have a right to receive a copy of the Center’s termination of the Patient and Center Relationship policy.

Reasons for which we may stop seeing you include:

• 1. Failure to obey our rules, such as keeping scheduled appointments
• 2. Intentional failure to report accurately your financial status
• 3. Intentional failure to report accurate information concerning your Patient and Center Rights and Responsibilities health or illness
• 4. Intentional failure to follow the health care program, such instructions about taking medications, personal health practices, or follow-up appointments, as recommended by your provider, and/or
• 5. Creating a threat to the safety of the staff and/or other clients

• If we have given you notice of termination of the patient and Center relationship, you have the right to appeal the decision to the Executive Director. Unless you have a medical emergency, we will not continue to see you as a patient while you are appealing the decision.·
• You are responsible for cooperating with Centro San Vicente to uphold Safety Standards and participate in activities that are designed for your safety and the safety of others, during your visit.

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