Associated Homecare, Inc.

PATIENT BILL OF RIGHTS The patient or the patients legal representative has the right to be informed of the patients right through effective means of communication. The agency must protect and promote the exercise of these rights as follows: You have the right to be informed of your rights as a patient of ASSO !AT"# $O%" A&"' !( . )e at ASSO !AT"# $O%" A&"' !( . will protect and promote the exercise of these rights. Your family or guardian may exercise your rights for you should you be unable. Your rights are as follows: *. You have the right to have your property treated with respect. +. You have the right to voice grievances regarding treatment or care that is ,or fails to befurnished' or regarding the lac. of respect for property by anyone who is furnishing services on behalf of ASSO !AT"# $O%" A&"' !( . You will not be sub/ected to discrimination or reprisal. 0. ASSO !AT"# $O%" A&"' !( . will investigate complaints made by you or your family or guardian regarding treatment or care that is ,or fails to be- furnished' or regarding the lac. of respect for your property by anyone furnishing services on behalf of the agency. We ask that you contact the Administrator Geor!ine "# O$ens RN immediate%y $ith any &ro'%ems you may encounter at( )*+,-./01/+2/ . )e will document any problems and the resolution to those problems and .eep a record of this in our agency for purposes of official review. 1. You have the right to be informed in advance about the care to be furnished' of any changes in the care to be furnished' the services and disciplines you will receive and the fre2uency of visits proposed to be furnished. 3. You have the right to be informed in advance of any change in the plan of care before the change is made and the right to participate in planning the care or treatment and in planning changes in the care or treatment' including reasonable discharge notice. 4. You have the right to confidentiality of your clinical record. The releases you sign are to allow us to release information to your insurance carrier' %edicare or %edicaid. (o information will be released to anyone without your written permission. You have the right under !ndiana law to access your clinical records unless certain exceptions apply. 5lease contact 6eorgine Owens' &( with your re2uest. 7. You have the right to be advised' orally and in writing' before care is initiated' of the extent to which payment for agency services may be expected from %edicare' %edicaid or other insurance and the extent to which payment may be re2uired from you and what services will not be covered by your insurance' %edicare or %edicaid. This is the overage of Service form we will leave with you. 8. You have the right to be advised orally and in writing of any changes in the information provided from your insurance' %edicare' or %edicaid regarding any changes in your benefit coverage within *3 calendar days from the time ASSO !AT"# $O%" A&"' !( . becomes aware of those changes. As an employee of ASSO !AT" $O%" A&"' !( . ! understand the above patient rights and my responsibilities in upholding these rights. ! understand that violating any patient right may result in my termination or other disciplinary action. Signature: 9999999999999999999999999999999999999 #ate: 99999999999999999999