As a Patient You Have the Right To:

• Be informed of rights (both verbally and in writing) as a patient (or patient’s representative) prior to, or when discontinuing, the provision of care. A list of these rights shall be posted within the Ambulatory Surgery Center so that such rights may be read by all patients.
• Exercise these rights without regard to age, race, disability, sex or cultural, economic, education, or religious background or the source of payment for care given.
• Formulate advance directives regarding patient’s healthcare, and have Ambulatory Surgery Center staff and practitioners who provide care in the Ambulatory Surgery Center comply with these directives (to the extent provided by state laws and regulations).
• Be treated with dignity and receive considerate and respectful care provided in a safe environment free from all forms of abuse, neglect or harassment.
• Remain free from seclusion or restraints of any form that are not medically necessary.
• Expect reasonable safety while in the Ambulatory Surgery Center.
• The name of the physician and staff who will be providing care and the name and professional relationships of other physicians and non-physicians who will participate in care.
• Receive appropriate information regarding provider credentialing.
• Receive as much information about any proposed treatment or procedure as needed in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternate course of treatment or non-treatment and the risks involved in each in terms the patient can understand. ENT Surgery Center will not honor DNR (Do Not Resuscitate) orders on any patient in this surgery center.
• Participate actively in decisions regarding medical care. To the extent permitted by law, this includes the right to request and/or refuse treatment.
• Express a complaint regarding care or any violation of your rights without being subjected to discrimination or reprisal.
• Be advised of the Ambulatory Surgery Center’s grievance process should the patient wish to communicate a concern regarding the quality of the care patient receives. Notification of the grievance process includes:  whom to contact to file a grievance, and that patient will be provided with a written notice of the grievance determination that contains the name of the Ambulatory Surgery Center contact person, the steps taken on patient’s behalf to investigate the grievance, the results of the grievance and the grievance completion date.
• Change physicians if desired, either within the Ambulatory Surgery Center or another physician of the patient’s choice.
• Full disclosure of the privacy policy and full consideration of privacy concerning the medical care program. Confidential treatment of case discussion, consultation, examination and treatment, and all communications and records pertaining to patient’s care at the Ambulatory Surgery Center. The patient has the right to be advised as to the reason for the presence of any individual involved in the patient’s healthcare.  The patient’s written permission shall be obtained before medical records can be made available to anyone not directly concerned with patient’s care.
• Access information contained in patient’s medical records within a reasonable time frame in accordance with state/federal laws and regulations.
• Reasonable responses to any reasonable requests made for service.
• Leave the Ambulatory Surgery Center even against the advice of the attending physician.
• Reasonable continuity of care.
• Be informed by the attending physician or designee of the continuing health care requirements following discharge.
• Obtain information before scheduled surgery about payment requirements of the bill, regardless of source of payment. Examine and receive an explanation of the bill regardless of source of payment.
• If eligible for Medicare, to know upon request and in advance of treatment whether a healthcare provider or facility accepts the Medicare assignment rate.
• Be advised if physician/Ambulatory Surgery Center proposes to engage in or perform human experimentation affecting the care or treatment. The patient has the right to refuse to participate in such research projects or clinical trials.
• Receive appropriate knowledge regarding absence of malpractice insurance.

All Ambulatory Surgery Center personnel, medical staff members and contracted agency personnel performing patient care activities shall observe these patients’ rights.

As a Patient You Have the Responsibility To:

• The care a patient receives depends partially on the patient himself. Therefore, in addition to these rights, a patient has certain responsibilities as well. These responsibilities should be presented to the patient in the spirit of mutual trust and respect:
• Provide accurate and complete information about present complaint, past illnesses, hospitalizations, any medications, including over-the-counter products and dietary supplements and any allergies or sensitivities, and other matters related to your health status.
• Make it known whether course of treatment and what is expected of the patient is clearly understood.
• Follow the treatment plan established by the physician, including the instructions of nurses and other health professionals as they carry out the physician’s orders.
• Provide a responsible adult to remain at the ASC during the patient’s stay, to transport the patient to the ASC and then home and remain with the patient for 24 hours if required by the physician.
• Keep appointments and notify the Ambulatory Surgery Center or physician when unable to keep an appointment.
• Accept responsibility for any actions resulting from the refusal to follow treatment or physician’s orders.
• Inform the physician about any living will, medical power of attorney, or other directive that could affect the patient’s care.
• Accept and ensure that the financial obligations of care are fulfilled as promptly as possible.
• Follow Ambulatory Surgery Center policies and procedures.
• Be considerate of the rights of other patients and Ambulatory Surgery Center
• Behave respectfully toward all healthcare professionals, staff, and other patients.
• Non-biological parents are responsible for informing the Ambulatory Surgery Center that you are foster/guardian/adoptive parents.

ENT Surgery Center strives to provide excellent patient care and service. If you should have a concern or complaint, please tell us so we can work to satisfy your needs. Ask to speak to the Clinical Manager.

Ownerships

Please be advised that Dr. Zoller, Dr. Daniel, Dr. Rashleigh, Dr. Moretz, and Dr. Rawlings own an interest in ENT Surgery Center. You are entitled to obtain the services for which you have been referred to ENT Surgery Center at the location of your choice.

Alternative sources of the services for which you have been referred to this entity are as follows:

Candler/St. Joseph’s Hospital

5353 Reynolds Street

Savannah, GA  31405

Memorial UMC Hospital

4700 Waters Avenue

Savannah, GA 31404

Advance Directives

• ENT Surgery Center is an outpatient surgery center that is limited to elective surgery only and performs no high-risk surgical procedures.
• It is the policy of ENT Surgery Center to recognize the Health Care Agent of the patient should circumstances require, but in the event of an emergency the patient will be stabilized and transferred to a hospital as soon as possible.
• Therefore, ENT Surgery Center will not acknowledge DNR (Do Not Resuscitate) orders on any patient while in this Ambulatory Surgery Center.
• For information on advance directives, click here.

Grievances

If the patient has concerns about the care being provided in this licensed ambulatory surgical treatment center, they may express concern to the Clinical Manager who can be reached as follows:

• Phone: 912-920-6911
• Fax: 912-920-1998
• 13040 Abercorn Street, Suite 3,

Savannah, GA 31419

If necessary, they may also file a complaint with the Georgia Department of Community Health, who can be reached as follows:

• Phone: 404-657-5728 or 1-800-878-6442
• Fax: 404-657-5731
• Georgia Department of Community Health, Complaints Division

Two Peachtree Street, NW, 31^st Floor

Atlanta, GA 30303-3142

You can also visit the website for the Office of the Medicare Beneficiary Ombudsman here.

This notice is posted as required by regulation of the Department of Public Health and Medicare CFC.