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health care facility recognize your rights while you are receiving medical care
and that you respect the health care provider’ s right to expect certain
behavior on the part of patients. You may request a copy of the full text of
this law from your health care provider or health care facility. A summary of
your rights and responsibilities follows: <o:p></o:p></p><p class="MsoNormal"><u>You have the right to: <o:p></o:p></u></p><p class="MsoNormal">• A patient has the right to be treated with courtesy and
respect, with appreciation of his or her individual dignity, and with
protection of his or her need for privacy. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to a prompt and reasonable
response to questions and requests. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to know who is providing medical
services and who is responsible for his or her care. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to know what patient support
services are available, including whether an interpreter is available if he or
she does not speak English. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to know what rules and regulations
apply to his or her conduct. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to be given by the health care
provider information concerning diagnosis, planned course of treatment,
alternatives, risks, and prognosis. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to refuse any treatment, except as
otherwise provided by law. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to be given, upon request, full
information and necessary counseling on the availability of known financial
resources for his or her care. <o:p></o:p></p><p class="MsoNormal">• A patient who is eligible for Medicare has the right to
know, upon request and in advance of treatment, whether the health care
provider or health care facility accepts the Medicare assignment rate. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to receive, upon request, prior to
treatment, a reasonable estimate of charges for medical care. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to receive a copy of a reasonably
clear and understandable, itemized bill and, upon request, to have the charges
explained. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to impartial access to medical
treatment or accommodations, regardless of race, national origin, religion,
handicap, or source of payment. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to treatment for any emergency
medical condition that will deteriorate from failure to provide treatment. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to know if medical treatment is
for purposes of experimental research and to give his or her consent or refusal
to participate in such experimental research. <o:p></o:p></p><p class="MsoNormal">• A patient has the right to express grievances regarding
any violation of his or her rights, as stated in Florida law, through the
grievance procedure of the health care provider or health care facility which
served him or her and to the appropriate state licensing agency. <o:p></o:p></p><p class="MsoNormal"><o:p>&nbsp;</o:p></p><p class="MsoNormal"><u>You have the responsibility to: <o:p></o:p></u></p><p class="MsoNormal">• A patient is responsible for providing to the health care
provider, to the best of his or her knowledge, accurate and complete
information about present complaints, past illnesses, hospitalizations,
medications, and other matters relating to his or her health. <o:p></o:p></p><p class="MsoNormal">• A patient is responsible for reporting unexpected changes
in his or her condition to the health care provider. <o:p></o:p></p><p class="MsoNormal">• A patient is responsible for reporting to the health care
provider whether he or she comprehends a contemplated course of action and what
is expected of him or her. <o:p></o:p></p><p class="MsoNormal">• A patient is responsible for following the treatment plan
recommended by the health care provider. • A patient is responsible for his or
her actions if he or she refuses treatment or does not follow the health care
provider’s instructions. <o:p></o:p></p><p class="MsoNormal">• A patient is responsible for assuring that the financial
obligations of his or her health care are fulfilled as promptly as possible. <o:p></o:p></p><p class="MsoNormal">• A patient is responsible for following the Clinic rules
and regulations affecting patient care and conduct. <o:p></o:p></p><p class="MsoNormal">• A patient is responsible for keeping appointments and,
when he or she is unable to do so for any reason, for notifying the health care
provider. <o:p></o:p></p><p class="MsoNormal"><o:p>&nbsp;</o:p></p><p>





















































</p><p class="MsoNormal"><i>The undersigned certifies that he/she has read the
foregoing, understands it, accepts its terms, has received a copy of it and is
the patient or is duly authorized by the patient as their agent to execute
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