PATIENT RIGHTS AND PATIENT RESPONSIBILITIES

To be treated with respect, consideration and dignity at all times

To receive assistance in a responsible manner

To receive information about your health, including associated risks that may involve procedures and medical alternatives and medications including risks to your health.

To know the identity and professional status of individuals providing services for you.

To refuse treatment and sign that you are advised of the consequences of refusing or delaying treatment.

To express any complaint to the Practice Provider and Managers at any time.

To know, review, and understand, YOUR health insurance coverage and benefits, including co-pays for visits and to give any changes in coverage to our office immediately.

To learn and understand the insurance plan restrictions on procedures covered, how often, what laboratory restrictions you have and facilities and doctors you may see. To carry and have available for verification insurance cards, driver’s license and identification at all times.

To treat our office staff with respect. To treat our physicians and their time with respect by following office procedures for appointments, billing, prescription refills etc. Failure to do so may result in after hours phone fees, or fees for "no show" appointments.

To pay all charges for co-pays, deductibles, non-covered services at the time of your visit.

To ask questions so that you fully understand the care, medication and procedures you may receive. I understand and acknowledge that any request for medical records must be done so on our form and appropriate fees apply.

To follow the providers advice and instructions for care and medications. To question anything you do not understand at the time of the visit and to report immediately any adverse reactions. Refusal to comply with advice and guidance may result in dismissal from the practice for non-compliance.

To provide honest and complete health information so that the provider may make informed decisions on your healthcare, including all medication lists and dosages you currently are taking from any physician or practice.

To understand that there may often be times when follow up care is needed and you may have to return to the office for that care.

To understand that late arrivals may result in having to be rescheduled, however we will try our best to see you on the appointed day. Please be mindful of the rights of other patients who are there as well.

I have read, understand and agree to abide by the office policy statements above and accept full responsibility as described. I give my consent to obtain treatment from Arista Ob/Gyn Associates, P.C.

Patient____________________________________Date__________________________________20040626