RIGHTS AND RESPONSIBILITIES OF RECIPIENTS – OUTPATIENT SERVICES
RETENTION OF
RIGHTS
1a. As a general rule, you lose none of your rights, benefits, or privileges simply because you are a recipient of mental health
or developmental disabilities services. For example, you have the right to vote and to choose services by spiritual means
through prayer.
1b. No one will be denied service at this facility based on their age, sex, sexual orientation, race, religious belief, ethnic
origin, marital status, physical, mental disability, HIV status, criminal record unrelated to present dangerousness and
regardless of source of payment.
2.
No recipient of services shall be presumed legally disabled nor shall such person be held legally disabled except as
determined by a court.
HUMANE CARE
SERVICES PLAN
3a. You are entitled to adequate and humane care and services in the least restrictive environment and an individual
services plan. A qualified professional shall be responsible for the implementation and periodic review of the treatment
plan, including the Recipient's and, as appropriate, family’s input. You have the right to see your clinical records.
3b. You or your legally designated representative has access to the information contained in the patient’s medical record,
within the limits of the law.
3c. You have the right to confidential HIV/AIDS status and testing and anonymous testing as specified in Section 2060.321.
3d. You have the right to nondiscriminatory access to services as specified in the American’s With Disabilities Act of 1990
(42 USC 12101).
3e. You have the right to know the costs, risks, and benefits of all treatment procedures and to know if limitations to duration
of service exist.
MAIL/VISITING
PHONE CALLS
4.
You have the right to communicate with other people in private, without obstruction or censorship by the staff at
the facility. Communication may be reasonably restricted by the Director of the Facility, but only to protect you or others
from harm, harassment, or intimidation.
PROPERTY
5.
You are entitled to receive, possess, and use personal property unless it is determined that certain items are harmful to
you or others.
MONEY/ BANKING
6.
You may use your money as you choose.
LABOR
7.
You must be paid for work you are asked to perform which benefits the facility. But note: You may be required to do
personal housekeeping chores without being paid.
REFUSING
SERVICES
8.
If you are an adult recipient of services, or under guardianship, you or your guardian shall be given the opportunity
to refuse generally accepted mental health or developmental disability services, including but not limited to medication.
If such services are refused they shall not be given unless such services are necessary to prevent the recipient from
causing serious harm to himself or others. The facility director, and/or outpatient clinician will inform the recipient or
guardian who refused such services of alternate services, as well as the possible consequences to the recipient of refusal of
such services.
RESTRAINT/
SECLUSION
9. Restraint and Seclusion may be used only as a therapeutic measure to prevent a recipient from causing physical harm
to himself or physical abuse to others. Restraint may only be applied by a staff person who has been trained in the
application of the particular type of restraint which is to be utilized.
In no event shall restraint or seclusion be utilized to punish or discipline a recipient, nor as a convenience for the staff.
A recipient, including those under guardianship, may request that any person of his choosing be notified of the
restraint/seclusion, whether or not the guardian approves such notice.
ABUSE AND
NEGLECT
10. Every recipient of services in a mental health or developmental disability facility shall be free from abuse and neglect.
UNUSUAL
SERVICES
11. You will not receive electro-convulsive therapy (electroshock treatment) or any unusual, hazardous, or experimental
services without your written and informed consent.
MEDICAL OR
DENTAL
12. Except in emergencies, no medical or dental services will be provided to you without your informed consent.
Rights & Responsibilities of Recipients – Outpatient
Form #6010-217
5/12
Page 1 of 4
INITIALS_______________
RESTRICTION
OF RIGHTSPERSONS TO
NOTIFY
13. If your rights are restricted, the facility must notify:
a.
Your parent or guardian, if you are under the age of 18;
b.
The person or agency of your choice
c.
The Facility Director.
d.
The Guardianship and Advocacy Commission if you request.
A Guardianship and Advocacy Commission has been created which consists of three divisions: Legal Advocacy
Service, Human Rights Authority, and the Office of the State Guardian. The Commission is located at:
421 E. Capitol Avenue, Ste 205
State of Illinois Building
Springfield, IL 62701
160 N. LaSalle Street, Ste 500
217-785-1540
Chicago, IL 60601 (312-793-5900)
Notification will be made to the recipient and designated person(s) upon implementation and termination of the
restriction(s).
PATIENT
ADVOCACY
CUSTOMER
CONCERN
14. If you have a problem or complaint, we want to help. Please let us know. Talk to your Therapist about any concerns
or ask to speak to the Clinical Director or Office Manager. If you are unable to resolve your concern, please contact
your Patient Advocate, Pat Getchell at Ext. 8507.
If at any time you or your family believe that a legal right has been denied, restricted or have any other complain/
Concern related to services received, you or they may contact your Patient Advocate. A staff person will assist you in
making the contact. Your Patient Advocate or representative is available at all times. Your complaint will be reviewed
and corrective action taken if indicated. You and, if appropriate, your family will receive a response from the Hospital
in a timely manner regarding your concerns.
PROGRAM
RELEASE OF
15. Release of verbal and written information regarding a recipient's care as well as access to review a recipient's chart can
INFORMATION/
only be made with written consent as follows:
CONFIDENTIALITY
a.
Attorney or guardian representing a minor over 12 in an administrative proceeding.
b.
Parent or guardian of a recipient at least 12 but under 18, if the recipient is informed and does not object, or the
therapist does not find compelling reasons for denying access.
c.
Parent or guardian of a recipient under age 12.
d.
Recipient 18 years of age or older.
e.
Guardian of a legally adjudicated disabled recipient 18 years of age or older.
However, relevant laws require that your clinician contact others about your safety if you present a danger to
yourself or others, if your clinician learns of child abuse or neglect or if ordered by the court. Your clinician may
consult with other clinicians within the ABBHH system to improve the quality of treatment.
You may request in writing a limit on the medical information we use or disclose about you for treatment, payment,
or healthcare operations and may request that we limit the medical information disclosed about you to someone who
is involved in your care or payment for your care, except when specifically authorized by you or when required by law
or in an emergency.
The undersigned authorizes ABBHH, my physician(s) and allied health professionals to discuss with and release
copies of the pertinent information from my medical records to employer groups, review organizations, insurance
companies, government agencies and/or third party payers and their agents for payment purposes. I understand that
this information concerning medical care, advice or treatment may consist of records of laboratory, diagnostic
tests and other medical information regarding mental illness, alcohol abuse, drug abuse, Human
Immunodeficiency Virus (HIV), Hepatitis or other infectious agents as may be necessary for payment of my
hospital and medical claims. This release also allows information to be released for utilization management and
financial audits.
I am aware that my medical information and medical records are privileged and confidential and as such are subject
to disclosure upon my authorization only, except where provided by law. I am also aware that only such information
as reasonably believed necessary shall be released and disclosed in order to satisfy the persons or organizations
requesting or needing the information.
I understand that I may request restrictions on the use or disclosure of my health information. If I refuse to consent
to the use or disclosure of my medical information and records for treatment, payment or health care operation
Rights & Responsibilities of Recipients – Outpatient
Form #6010-217
5/12
Page 2 of 4
purposes, I understand that ABBHH need not treat me. I acknowledge that the authorization is valid until such time
as all available insurance benefits have been received. According to federal law, I understand that if I revoke this consent
after services have been provided to me, the revocation will not affect ABBHH’s ability to disclose my health
information to seek reimbursement for the care provided.
INITIALS_______________
PATIENT
RESPONSIBILITIES
16. The patient is responsible for providing, to the best of his/her knowledge, accurate and complete information
about present conditions, past illnesses, hospitalizations, medications, and other matters relating to his/her health.
The patient and family are responsible for reporting unexpected changes in the patient’s conditions. The patient
and family help the hospital improve it’s understanding of the patient’s environment by providing feedback about
service needs and expectations.
17. Patients are responsible for asking questions when they do not understand what they have been told about their
care or what they are expected to do.
18. The patient and family are responsible for following the care, service, or treatment plan developed. They should
express any concerns they have about their ability to follow and comply with the proposed care plan or course
of treatment. Every effort is made to adapt the plan to the patient’s specific needs and limitations. When such
adaptations to the treatment plan are not recommended, the patient and family are responsible for understanding
the consequences of the treatment alternatives and not following the proposed course of treatment.
PATIENT PRECERTIFICATION
RESPONSIBILITY
19. I understand that I am responsible for the notification of my insurance company to obtain any necessary
authorization before services are rendered. I further understand that if I do not pre-certify my treatment,
I may incur a reduction or loss of benefits paid to ABBHH, for which I will be responsible.
ASSIGNMENT
OF INSURANCE
BENEFITS AND
PAYMENT
GUARANTEE
20.
REQUEST FOR
HOSPITAL
ADMISSION
AND CONSENT
FOR MEDICAL
TREATMENT
21. I, the undersigned, am the patient (or the patient’s duly authorized representative) and do hereby voluntarily
present for medical treatment and consent to my attending physician and whomever he/she may designate as
assistants, associates or treatment physicians, as well as ABBHH and its employees, allied health professionals and
select independent contractors, to provide me with medical care. Such care may include routine services such as
diagnostic procedures, psychotherapeutic treatment, other treatments and procedures considered medically advisable
in the diagnosis and treatment of my condition. I recognize that any or all physicians and allied staff professionals
who furnish services to me during this admission may be independent contractors, and as such are not agents or
employees of ABBHH. I understand and agree that the practitioners referenced above bill and collect independently
for their services. I understand that their bills will be separate and apart from ABBHH’s billing and collections,
or that ABBHH may bill on the physician’s behalf. I understand that I may be requested to execute one or more
informed consent forms that authorize my physician or his/her designee to diagnose and/or treat my condition.
Prior to signing any such consent form, I will have an opportunity to discuss my condition, the recommended
course of treatment, treatment alternatives and associated hazards with my physician or his/her designee. I may at
any time refuse treatment or withdraw my consent for the performance of any specific procedure or the release of
medical information. Should I refuse medical care or revoke a previous consent, I will be requested to sign a
form so acknowledging. I recognize that the practice of medicine, surgery, psychiatry or counseling is not an exact
science and, therefore, acknowledge that no guarantees have been or can be made regarding the likelihood of success
or outcome of any diagnosis or treatment performed at ABBHH. I have read the above and certify that I have
had an opportunity to discuss the contents herein to my satisfaction. By signing this form, I am requesting admission
to ABBHH and consenting to such routine and therapeutic care as my physician or his/her designee deems necessary.
MEDICARE
22. I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct.
I authorize any holder authorization of medical or other information about me to release to the Social Security
Administration or its intermediaries or carriers any information needed for this or related Medicare claims. I request that
In consideration for the care, treatment and services rendered by my physician(s), ABBHH agents and employees
and allied health professionals, I hereby assign, transfer and set over to my treatment physician(s) and ABBHH
all of my rights, title and interest to medical reimbursement including, but not limited to, all rights to appeal
and obtain administrative and judicial review of any denial of benefits for healthcare services rendered to me by
my physician(s) or ABBHH’s agents or employees. In consideration of the services to be rendered, I agree to pay
the account of ABBHH in full in accordance with the billing and collection policies of ABBHH. I further agree to
pay the account in full within 45 days from the date of discharge unless satisfactory arrangements are made with
ABBHH. Should the account be referred to any attorney or collection agency for collection, I agree to pay any
related attorney or agency fees.
Rights & Responsibilities of Recipients – Outpatient
Form #6010-217
5/12
Page 3 of 4
payment of authorized benefits be made on my behalf directly to ABBHH and my treating physician(s) and allied health
professionals. I authorize the Social Security Administration to release my Medicare number, Part A and/or Part B
eligibility effective dates and birth date to ABBHH. My initials acknowledge my receipt of "An Important Message from
Medicare or CHAMPUS” from ABBHH on the date noted and do not waive any of my rights to request a review or make
me liable for payment.
INITIALS_______________
23.
I certify that I hereby give consent for an ABBHH staff member to send me a letter or e-mail of encouragement sometime
after discharge.
24.
I certify that it has been explained to me that by initialing here, that I hereby give consent to be contacted by Professional
Research Consultants (PRC) regarding the Outpatient treatment received. By leaving blank, I do not grant permission to
be contacted.
A copy of this summary of rights was provided to the recipient:
Recipient’s Guardian
A copy of the program location and hours during which care, treatment and services
are available was provided to the recipient:
Yes
Yes
No
No
NA
Yes
No
NA
The above rights were read and explained to me. I acknowledge receipt of this form and the summary of these rights. I acknowledge receipt of
ABBHH Notice of Privacy Practices. The Notice of Privacy Practices provides detailed information about how the hospital may use and
disclose my confidential health information. I understand that ABBHH has reserved the right to change its privacy practices that are described
in the notice. I also understand that a copy of any Revised Notice will be provided to me or made available.
____________________
Date
_________________________________________
Patient
____________________________________________________________
Signature of Employee
__________________________________________
Guardian (if applicable)
_______________________________________
Title
Rights & Responsibilities of Recipients – Outpatient
Form #6010-217
5/12
Page 4 of 4