Patient Bill Of Rights
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1<Patient Demographic Identifier Sticker>
Ambulatory Surgery and Laser Center
of Cape Cod
280 Heritage Park
Sandwich, Ma 02563
Patient’s Bill of Rights
As a patient you have the right to:
Considerate, respectful care at all times and under all circumstances with recognition of your
personal dignity
Personal and informational privacy, within the law
Information concerning your diagnosis, treatment, prognosis, to the degree known
Confidentiality of records and disclosures. Except when required by law you have the right
to approve or refuse the release of your medical records.
The opportunity to participate in decisions involving your healthcare
The right to make decisions about medical care, including the right to refuse or accept
medical or surgical treatment
The right to initiate an Advance Directive such as Living Will or Durable Power of Attorney
Impartial access to treatment regardless of race, color, sex, national origin, religion,
disability, or ability to pay
Receive an itemized bill for services received
Know the identity and professional status of all persons providing service to you
Report all comments, questions or concerns concerning the quality of care you received and
receive timely follow-up from Facility management
Information about pain and pain management relief measures provided by staff committed to
pain prevention and management in a timely manner.
As a patient you are responsible for:
Providing accurate and complete information about your present health status and past
medical history and reporting any unexpected changes to the appropriate practitioner
Following the treatment plan recommended by the practitioner involved in your care
Providing an adult to transport you home after surgery and stay with you as needed
Indicating that you clearly understand what is expected of you after your surgery/procedure
Your own actions should you refuse treatment, leave the Facility against medical advise, or
choose to purposefully not follow the instructions of your practitioner
Providing information and/or copies of an Advance Directive such as Living Will or Durable
Power of Attorney
Ask your health professional what to expect for pain management; discuss pain relief
options; discuss openly any concerns or fears regarding pain management medications
____________________________
___________________________
Print Name
Signature
__________________
____________________ ____________________________________
Date
Time
Witness
7/2011
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