Southpointe Psychiatry & Wellness
PATIENTS RIGHTS
Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and the release of information must be completed. Furthermore, there is a minimum processing fee $15.00. Please make your request well in advance and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right to review, which I will discuss with you upon request.
Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You must make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.
Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you complete this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. At your request, I will discuss with you the details of the accounting process.
Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
Right to Choose – You have the right to decide not to receive services with me. If you wish, I will provide you with the names of other qualified professionals.
Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.
Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether I think releasing the information in question to that person or agency might be harmful to you.
Your Responsibilities as a Patient
You are responsible for being open and honest with your provider about your health history, including all medications (both prescription and over the counter) you are taking.
You are responsible for following the suggestions and advice prescribed in a course of treatment by your healthcare provider(s).
You are responsible for asking questions and making sure you understand the instructions given to you.
You are responsible for keeping appointments and arriving on time.
You are responsible for following health care facility rules and regulations that apply to your conduct as a patient.
You are responsible for presenting an insurance identification card prior to receiving health care services, verify that the physician/healthcare facility is an in-network provider, pay any necessary copayment at the time you receive treatment, and be aware of your benefit plan.
You are responsible for notifying your health care provider of demographic updates as well as changes in membership or dependent coverage.
You are responsible for expressing your concerns to your caregivers in a respectful manner, being considerate of the rights of other patients, and respecting Southpointe Psychiatry & Wellness’ personnel and property.
You are responsible for keeping Southpointe Psychiatry & Wellness tobacco- and smoke- free. You may not smoke, use e-cigarettes (vape), or use tobacco products while in this facility.
You are responsible for keeping Southpointe Psychiatry & Wellness a safe environment. You may not bring alcohol, illegal drugs, and/or weapons to the practice.
Patient Name: _________________________________ Date: ____________________________
Patient/Guardian Signature: ________________________________________________________