{"id":11,"show_publish_options":false,"fields":[{"settings":{"objectType":"Field","objectDomain":"fields","editActive":false,"order":1,"label":"HTML","type":"html","default":"<p class=\"MsoNormal\">Florida law requires that your health care provider or\nhealth care facility recognize your rights while you are receiving medical care\nand that you respect the health care provider’ s right to expect certain\nbehavior on the part of patients. You may request a copy of the full text of\nthis law from your health care provider or health care facility. A summary of\nyour 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\nrespect, with appreciation of his or her individual dignity, and with\nprotection 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\nresponse to questions and requests. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to know who is providing medical\nservices 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\nservices are available, including whether an interpreter is available if he or\nshe does not speak English. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to know what rules and regulations\napply 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\nprovider information concerning diagnosis, planned course of treatment,\nalternatives, risks, and prognosis. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to refuse any treatment, except as\notherwise provided by law. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to be given, upon request, full\ninformation and necessary counseling on the availability of known financial\nresources for his or her care. <o:p></o:p></p><p class=\"MsoNormal\">• A patient who is eligible for Medicare has the right to\nknow, upon request and in advance of treatment, whether the health care\nprovider 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\ntreatment, 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\nclear and understandable, itemized bill and, upon request, to have the charges\nexplained. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to impartial access to medical\ntreatment or accommodations, regardless of race, national origin, religion,\nhandicap, or source of payment. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to treatment for any emergency\nmedical 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\nfor purposes of experimental research and to give his or her consent or refusal\nto participate in such experimental research. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to express grievances regarding\nany violation of his or her rights, as stated in Florida law, through the\ngrievance procedure of the health care provider or health care facility which\nserved him or her and to the appropriate state licensing agency. <o:p></o:p></p><p class=\"MsoNormal\"><o:p>&nbsp;</o:p><u>You have the responsibility to:</u></p><p class=\"MsoNormal\">• A patient is responsible for providing to the health care\nprovider, to the best of his or her knowledge, accurate and complete\ninformation about present complaints, past illnesses, hospitalizations,\nmedications, 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\nin 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\nprovider whether he or she comprehends a contemplated course of action and what\nis expected of him or her. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for following the treatment plan\nrecommended by the health care provider. • A patient is responsible for his or\nher actions if he or she refuses treatment or does not follow the health care\nprovider’s instructions. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for assuring that the financial\nobligations 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\nand regulations affecting patient care and conduct. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for keeping appointments and,\nwhen he or she is unable to do so for any reason, for notifying the health care\nprovider. <o:p></o:p></p><p class=\"MsoNormal\"><o:p>&nbsp;</o:p></p><p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n</p><p class=\"MsoNormal\"><i>The undersigned certifies that he/she has read the\nforegoing, understands it, accepts its terms, has received a copy of it and is\nthe patient or is duly authorized by the patient as their agent to execute\nabove.&nbsp;<br><o:p></o:p>Any form of electronic signature, such as facsimile or email scan, shall be deemed to be an original signature.</i></p>","container_class":"","element_class":"","key":"html_1596588884080","drawerDisabled":false,"wrap_styles_show_advanced_css":0,"label_styles_show_advanced_css":0,"element_styles_show_advanced_css":0,"cellcid":"c3362"},"id":"199"},{"settings":{"objectType":"Field","objectDomain":"fields","editActive":false,"order":2,"label":"Patient’s Signature or Legal Representative ","type":"firstname","key":"patient_s_signature_or_legal_representative_1596589076753","label_pos":"below","required":1,"default":"","placeholder":"","container_class":"one-half 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