Patient Forms

Patient Rights

• Confidential treatment of all information about your care except as required by state law.
• Privacy during any interview, exam, or treatment.
• Refusal to be examined, observed, or treated by students or staff without affecting your access to care.
• Refusal to serve as a research subject.
• Access to your health record as prescribed by law and the Center’s policy.
• Privacy respecting the source of payment for care and detailed explanation of all charges.
• Assistance and information about any health center bills or costs for services, or financial assistance and free health care if you are eligible.
• Information about the relationship, if any, between the Center or its providers and any other health care facility or educational institution.
• A friend, relative, or advocate who can act on your behalf during your health center visits.
• Lifesaving treatment, even if you don’t have insurance or cannot pay.
• Information about all the ways breast cancer can be treated (if you have breast cancer).
• Assistance and information about emergency contraception (if you are a female rape victim).
• Full information about Health Center services and policies.
• Be treated with respect and dignity.
• Courteous, convenient communication.
• Information about the name and qualifications of the persons involved with your care.
• Convenient appointment times, prompt attention, and an explanation if you are kept waiting.
• Consultation from another provider, if desired.
• Freedom to choose your provider or facility to the extent we are able to accommodate that choice.
• Ability to take part in all decisions regarding your care, with explanations for examinations and tests.
• Evaluation and effective management of pain, including information about options for pain relief.
• An interpreter at no cost to you.
• Prompt response to any reasonable requests.

Patient Responsibilities

• Provide an accurate and complete health history.
• Your provider may base many of his/her
• recommendations on this information.
• Inform Family Health Center if health care instructions provided are not clear or easily understood.
• Bring necessary personal and health coverage
• information to every visit.
• Help Family Health Center to meet financial obligations by keeping health insurance up to date and by paying charges and co-payments promptly.
• Treat Family Health Center staff, other patients/
• visitors, facilities and their property with respect and dignity.
• Follow the rules and regulations of the Health Center.

Patient Forms