CHEMED PATIENT BILL OF RIGHTS AND RESPONSIBILITIES

Each patient receiving service at CHEMED shall have the following rights and responsibilities:

Each patient has the right to be informed of these rights, as evidenced by the patient’s written acknowledgment, or by documentation by staff in the medical record, that the patient was offered a written copy of these rights and given a written or verbal explanation of these rights, in terms the patient could understand. The facility shall have a means to notify patients of any rules and regulations it has adopted governing patient conduct in the facility.

Courteous Treatment

The patient has the right to be treated with courtesy and respect by the CHEMED staff. The patient has the right to be free from mental and physical abuse, free from exploitation, and free from the use of restraints other than authorized by a physician for a limited time. The patient shall not be required to perform work for the facility unless the work is part of the patient’s treatment and is performed voluntarily by the patient.

Appropriate Health Care

The patient has the right to appropriate care based on individual needs. The care should enable the patient to achieve their highest level of physical and mental functioning. The patient has the right to expect and receive appropriate assessment, management and treatment of pain.

Information about Treatment

The patient has the right to be given complete and current information concerning their diagnosis, treatment, alternatives, risks and prognosis. This information should be in terms and language that the patient can understand. In cases where it is medically inadvisable, the patient’s guardian or another person named by the patient will be given the information. The patient has the right to be informed of services available in the facility, of the names and professional status of the personnel providing and/or responsible for the patient's care.

Participation in Planning Treatment

The patient has the right to participate in the planning of your health care. This right includes the opportunity to discuss treatment and alternatives with the provider. The patient who does not speak English shall have access, where possible, to an interpreter. Patients shall have the right to have an advance directive or health care proxy. The patient has the right to be informed if the facility has authorized other health care and educational institutions to participate in the patient’s treatment.

Right to Refuse Care

The patient has the right to refuse any and all treatment to the extent permitted by law, and to be informed of the medical consequence of such action. If the patient fails to follow their healthcare provider’s instructions, or if the patient refuses care, they are responsible for their own actions. The patient has the right to be included in experimental research only when the patient gives informed, written consent to such participation.

Confidentiality of Records

The patient has the right for their records to remain confidential, and may refuse their release to someone outside the facility program limited only by state statutes, rules, regulations, or imminent danger to the individual or others.

Personal Privacy

The patient has the right to every consideration of their privacy, individuality and cultural identity as related to their social, religious and psychological well-being. CHEMED staff must respect the patient’s privacy by knocking and seeking consent before entering, except in an emergency.

Financial Responsibility

The patient assumes financial responsibility for all services either through their insurance or by paying at the time of service.

Grievances

The patient has the right to voice grievances and recommend changes without fear of retaliation. To voice a grievance you may contact the CHEMED 1771 Madison Ave.  Lakewood N.J. 08701 Attn: Patient Satisfaction, (732) 364-2144 x214 or x111 (voicemail only) or The NJ Department of Health Complaint Hotline at 1-800-792-9770.

PATIENTS HAVE THE FOLLOWING RESPONSIBILITIES:

1. To provide the Health Center with accurate medical information.
2. To ask all questions they have regarding treatment provided by the Health Center.
3. To inform the Health Center if the medical procedures or instructions are not understood.
4. To follow after-care instructions as recommended by the Health Center.
5. To provide all necessary information regarding third-party payor sources or health insurance plans.
6. To observe the Health Center’s policies and procedures.
7. To keep scheduled appointments or advice the center if canceling.

NOTICE OF PRIVACY PRACTICES

We at CHEMED respect your privacy. This is part of our code of ethics. We are required by law to maintain the privacy of 'protected health information' about you, to notify you of our legal duties and your legal rights, and to follow the privacy policies described in our Notice of Privacy Practices. 'Protected Health Information' means any information that we create or receive that identifies you and related to your health or payment for services to you.

Every patient is given a Notice of Privacy Practices that explains how CHEMED may use or disclose your information for treatment, payment or operational purposes, as well as your legal rights regarding that information. Every patient is asked to sign a consent form to permit all such uses and disclosures. If you have questions about our policies and procedures, requests to exercise individual rights, or a concern about your privacy please speak to a receptionist or contact 732-364-2144, x206. You can also submit a complaint to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington D.C. 20201, Hotline: 1-800-368-1019. We will never retaliate against you for filing a complaint.

This practice serves all patients. Discounts for essential services are offered depending upon family size and income. You may apply for a discount at the front desk.
You are responsible for all charges. Copays must be paid at the time of service. Please bring your health insurance cards to all visits.
No child may be left alone on premises – even if the parent/guardian is in another area of the Health Center.

I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of myself/my child. I also attest that I have the right to consent for treatment for myself or I am the legal guardian and have the right to consent for the treatment of this child. I understand that I have the right to ask questions of my/my child’s service provider about the above information at any time.

General Consent for Examination and Treatment

I hereby consent and authorize Center for Health Education, Medicine and Dentistry (CHEMED) and all providers and ancillary personnel of CHEMED, to perform physical examinations and provide routine health care for all my visits to CHEMED.  This may include routine examinations and treatment, diagnostic and laboratory procedures and tests, medication administration, and other routine care for which a specific informed consent form will not be signed by me.  This consent includes consent and authorization to photograph or otherwise take images of me and/or parts of my body for purposes of identification, diagnosis, treatment, payment and healthcare operations of CHEMED.  Any photographs or other images taken will become part of my health record.  CHEMED will not use such photographs or images for any other purposes without my specific written consent.  I understand that certain procedures will require a specific informed consent, and that CHEMED will provide me with information and forms prior to such procedures.

Agreement

In consideration of the examination to be provided by Center for Health Education, Medicine and Dentistry (CHEMED): I understand that the doctor makes no representation about my condition other than those concerning the problem for which he has been retained. Patients have the right to formulate an advance directive. I hereby authorize CHEMED to furnish information to insurance carriers regarding illness and treatments to me and/or my dependents in writing, by e-mail, fax or through electronic assignment to the appropriate parties as needed. I authorize release of all information necessary to secure payment. I hereby assign CHEMED any/all benefits/payments received from my insurer, including any person injury protection coverage received as a result of a liability settlement. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment and of this signature is to be considered valid. I agree to pay any deductible or other balance not paid by my insurer. I am responsible for all fees regardless of insurance reimbursement. Payment is required after each visit for medical services unless other payment arrangements are made. It is our policy that patients who are younger than 18 years of age must be accompanied by their parent/guardian. I have been offered and accept CHEMED Health Center’s Bill of Rights and Responsibilities.

I hereby authorize CHEMED Health Center to retrieve my prescription history from an external source. I understand that this authorization will remain in effect until such time that I specify in writing that my consent is no longer given.

Informed Consent For Controlled Dangerous Substances Use

I voluntarily request that CHEMED’s licensed healthcare professionals treat and manage me/my child. I authorize and give my consent for CHEMED’s licensed healthcare professionals to prescribe controlled dangerous substances, which I understand may be useful in treating and managing my/my child’s condition.

I understand that controlled dangerous substances may be harmful if taken without medical supervision, may have adverse side effects or results, and may lead to developing a physical or psychological dependence on, or addiction to, the controlled dangerous substances. 

I understand that there may be alternatives to using controlled dangerous substances to treat and manage my/my child’s condition.  I also understand that there are possible risks and complications, as listed below, associated with using controlled dangerous substances.  I understand that this list is not complete and even when used as directed, additional risks are possible including physical dependence, tolerance, misuse and abuse, addiction, relapse of addiction symptoms, overdose, and death.

I have furnished a complete and accurate medical history (including pregnancy, if applicable) and list of the medications that I am/my child’s is currently taking or have taken in the last 6 months, including without limitation, information about the mental history and recreational drug and/or alcohol use by me/my child and members of the family.

If I am/my child is being prescribed a controlled substance, I acknowledge that I have been made aware of the following information and agree to the following conditions:

1. I am responsible for my/my child’s medications and agree to arrange to take the medications not more frequently than as prescribed and in accordance with all directions given.
2. There are risks and complications associated with taking controlled dangerous substances, which may include without limitation, skin rash, constipation, sexual dysfunction, sleeping abnormalities, sweating, edema, sedation, confusion, depression, increased sensitivity to pain, or the possibility of impaired motor ability.
3. I will inform my/my child’s CHEMED prescribers immediately of any adverse side effects or results from taking controlled dangerous substances.
4. I will inform my/my child’s CHEMED prescriber of any changes in other medications and/or over the counter drug use.
5. I will inform my/my child’s CHEMED prescriber of any recreational drug and/or alcohol so as to ensure the safe usage of the prescribed medications.
6. I understand that the prescription for controlled dangerous substances I have/my child has been given is for my/my child’s use and I attest that I will not give or sell any portion of the prescription to another individual.
7. Without prior disclosure to my/my child’s CHEMED prescriber, I will not request or accept controlled substance medications from any other healthcare provider or individual while I am/my child is receiving such medications from my CHEMED prescribers.
8. I understand that CHEMED will not issue early refill prescriptions and will only prescribe medications following a face-to face-consultation.  Telephone refills will be not be issued, unless otherwise noted on the prescription.
9. I understand that CHEMED may routinely contact other healthcare providers who have prescribed drugs for me/my child, and pharmacies that have dispensed drugs for me/my child, to determine if it is appropriate to prescribe or continue to prescribe controlled dangerous substances in connection with my/my child’s condition.
10. I understand that CHEMED may or, if required by law, shall access and search New Jersey’s prescription monitoring program information initially and quarterly in connection with any misuse or abuse of the medications prescribed for me/my child.
11. I understand that no warranty or guarantee has been made to me as to the results of the treatment or management of my/my child’s condition through the use of controlled dangerous substances.  I have been given the opportunity to ask questions about my/my child’s condition, treatment, and management, risks of non-treatment or management and the risks and complications involved, and I believe I have sufficient information to give informed consent on my/my child’s behalf.
12. I understand that non-compliance with the above-mentioned practices may result in discharge from the medication management department at Chemed.
    
    

Appointment Attendance Agreement

I am a patient at CHEMED Heath Center’s Department of Behavioral Health (“the Practice”)

I am seeking psychiatric consultation, medication management and/or psychotherapy from my provider in the Practice.

I understand that regular attendance at my treatment sessions, at appointment times agreed upon between my provider and myself, is extremely important. I understand that my treatment may be less helpful to me, and my condition may worsen, if I miss my appointments.

I agree to the following procedures regarding attendance at my appointments in the Practice:

1. If I need to cancel a scheduled appointment, I will contact my provider at least twenty-four (24) hours before the time of my appointment, unless an emergency occurs within those twenty-four (24) hours.
2. If I miss an appointment without cancelling at least twenty-four (24) hours in advance, my provider will attempt to contact me by telephone or letter to remind me of the missed appointment.
3. If I miss a second appointment with my CHEMED provider without cancelling at least twenty-four (24) hours in advance, I will receive a letter from my provider warning me that if I miss any further appointments without cancelling 24 hours in advance, my provider may discharge me from the Practice.
4. If I miss a third appointment with my CHEMED provider without cancelling at least twenty-four (24) hours in advance, my provider may decide that it would be best if I received treatment elsewhere. I understand this means I may be discharged from the Practice. If I am discharged from the Practice, I will receive a letter from the Practice letting me know when I will no longer be a patient of my CHEMED provider and giving me instructions on what I will need to do to find another provider.
   
   My CHEMED provider has talked to me about my behavioral health treatment and this agreement. I agree to follow the procedures as stated above. I was given time to ask my doctor questions about my behavioral health care and this agreement. By signing this agreement, it means I have read this agreement, or it has been read to me, I understand the agreement, and all my questions about this agreement have been answered.

Consent for Patient Reminders and Notifications

You are consenting to receive messages from us, your healthcare provider, that utilizes an automatic telephone dialing system to deliver a text, voice, or pre-recorded message that may contain health related information or healthcare management advice at the telephone number(s) that you have provided. You understand that you are not required to provide consent in order to receive such information or advice from your healthcare provider.

Terms & Conditions

Your request to receive automated voice and text messages from us, your healthcare provider, constitutes your agreement to these terms and conditions. You agree that we may send you automated voice and text messages through your wireless provider to the valid mobile or landline number that you have provided us. You agree to indemnify, defend, and hold us, our technology service vendor - healow LLC, our electronic medical record vendor - eClinicalWorks LLC, and its affiliated companies harmless from any third-party claims, liability, damages or costs arising from your request to receive automated voice or text messages or from providing us, your healthcare provider, with a phone number that is not your own. You agree that we and our technology solution vendors will not be liable for failed, delayed, or misdirected delivery of, any information sent to you or from you, including opt-out requests. You must be 18 years or older in order to participate or have the express permission of a parent/guardian (but in any case, you must be at least 13 years old). 
This is a standard-rate messaging program where message and data rates may apply. Frequency of messages may vary depending on the number of messages that you are due to be sent by your healthcare provider. 
Supported carriers include AT&T, Verizon Wireless, T-Mobile®, Metro PCS®, Sprint, Boost, Virgin Mobile, U.S. Cellular®, and others. Additional carriers may be added at any time. Carriers are not liable for delayed or undelivered messages. T-Mobile® is not liable for delayed or undelivered messages.

Frequently asked questions:

What sort of messages can we send you?

As your healthcare provider, our goal is to stay in touch with you even when you're not in their office. To keep the lines of communication open and based on need, we can send you messages via voice SMS/text, email and secure messages on the Patient Portal and using healow. Example of communication from our practice can include: appointment reminders, prescription refill messages and health/wellness notifications for tests or other procedures. We respect your need for privacy and will not send you telemarketing related messages or share your contact details with anyone.

What does it mean when you opt-in or activate?

By choosing to opt-in for voice and or text messages from us, your healthcare provider office, you are consenting to receive phone, text and/or other electronic messages to the number we have on file for you. We have chosen to use this automated service reminders offered by healow and eClinicalWorks. Please direct all your communication directly with us, your healthcare provider office and not our technology vendor companies.

Please note: Phone, emails and text messages are considered unsecure methods of contact and may result in disclosure of sensitive information to unauthorized individuals. You are assuming the risk involved by activating these services and will not hold the practice responsible.

Can you turn off these services later?

Yes, simply contact us, your healthcare provider office and ask to adjust your communication preferences. You can also text STOP on reply to a text message that you receive from us. On texting STOP, your phone number will be unsubscribed from this service and you will not receive any further health and wellness messaging notifications via text.

What if you need further help?

Please note that these services are either simply to remind you of important or necessary steps that you need to take for living a better healthier lifestyle or for offering you convenient ways to connect with us, your healthcare provider outside the walls of their clinic. If there is ever an emergency or if you need help, please call 911 or call our offices during regular working hours right away. Should you need additional help text HELP on reply to a text message and access the same message.

 

Did you know simple steps you take can protect your health information online?

Password protect any device from which you view or download your health information, both on your mobile phone or home computer. Make sure your password meets the criteria for a strong secure password which means it consists of a at least six characters and uses a combination of letters, numbers, and symbols. Also, if you are using a public computer to access your health information, be sure to log out.

Talk or text you soon!

I give permission for my Protected Health Information to be disclosed for purposes of communicating results and care decisions to the persons listed below: