I. Disclosure of Ownership
Cape Cod Eye Surgery & Laser Center (the Center) is a for-profit ambulatory surgery center owned by physicians. The physicians listed below have a partial ownership interest in the Center:
- Ann M. Bajart, MD
- Audrey S. Chan, MD
- Jeffrey S. Heier, MD
- Mami A. Iwamoto, MD
- John T. Mandeville, MD
- Michael G. Morley, MD
- Joshua J. Ney, MD
- Dale C. Oates, MD
- Michael F. Oats, MD
- Daniel J. O’Connor, MD
- Michael B. Raizman, MD
- Claudia U. Richter, MD
- Babak Jian Seyedahmadi, MD
- Bradford J. Shingleton, MD
- Gerald G. Tanguilig, MD
You have the right to personal privacy, receive care in a safe setting, and be free from all forms of abuse and harassment. You have the right to be treated with respect, consideration and dignity and be free from any act of discrimination or reprisal.
II. Patient Rights
- You have the right to considerate and respectful care without regard to race, sex, culture, economic, educational or religious background, or any other legally protected status. You have the right to receive respect for your cultural and spiritual beliefs.
- You have the right to know the name and specialty of the physician responsible for your care.
- You have the right to make informed decisions about your care. To that end, you have the right to obtain from your physician complete, current information concerning your health status, diagnosis, treatment and prognosis in terms you can be reasonably expected to understand to assure that you can effectively exercise your right to make informed decisions about your care. When it is not medically advisable to give such information to you, the information will be made available to an appropriate person on your behalf. You have the right to designate a person to receive such information.
- You have the right to informed consent, including the right to receive the information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for the informed consent will include but not be limited to the specific procedure and/or treatment and the expected outcome, the medically significant risks involved, and the probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when you request information concerning medical alternatives, you have the right to know the alternatives.
- You have the right to refuse treatment and/or to change physicians if other qualified physicians are available and be informed of the medical consequences of your action. You have the right to refuse to be examined, observed, or treated by students or certain other Center staff without jeopardizing access to medical care and attention at the Center.
- You have the right to have all reasonable requests responded to promptly and adequately within the capacity of the Center.
- You have the right to privacy concerning your medical care program. Case discussion, consultation, examination and treatment are confidential and will be conducted discreetly within the capacity of the Center. Those not directly involved in your care must have your permission to be present.
- You have the right to expect all communications and records pertaining to your care to be treated as confidential, to the extent provided by law. You will be given the opportunity to approve or refuse the release of your information, to the extent required by law.
- If non-emergent treatment is not provided by the Center because of your economic status or lack of a source of payment, you have the right to be transferred promptly and safely to a facility that agrees to receive and treat you. Prior to such transfer, the Center will: ascertain that you may be safely transferred, contact the facility willing to treat you, arrange the transportation, accompany you with necessary and appropriate professional staff to assist in the safety and comfort of the transfer, assure that the receiving facility assumes the necessary care promptly, and provide pertinent medical information about your condition. The Center also will maintain records of such transfer event.
- You have the right to request and receive information about the relationship between the Center and any other health care facility or educational institution, if any, and about your physician and his/her relationship with the Center and any other health care facility or educational institution, if any, to the extent that such relationship relates to your care or treatment. You have the right to obtain information as to the existence of any professional relationships among individuals, by name, who are treating you.
- You have the right to refuse to serve as a research subject and to refuse any care or examination when the primary purpose is educational or informational rather than therapeutic.
- You have the right to expect reasonable continuity of care, including knowing in advance what appointment times and physicians are available, and receiving information from your physician about your continuing health care requirements following discharge.
- You have the right to receive an itemized bill reflecting laboratory charges, pharmaceutical charges, and third party credits or reimbursements paid toward such bill, and examine an explanation of your bill, regardless of source payment; this information also shall be made available to your physician. You have the right, upon request, to receive a copy of an itemized bill or other statement of charges submitted to any third party by the Center for your care and to have a copy of the itemized bill or statement sent to your physician.
- You have the right, upon request, to receive from a person designated by the Center any information the Center has available relative to financial assistance and free health care.
- You have the right to know the Center’s rules and regulations and how they apply to your conduct as a patient.
- You have the right to access and inspect your medical records, and the right to receive a copy of your medical records upon completion and submission of a medical records release form and payment of the copying expenses.
- You have the right to prompt life saving treatment in an emergency without discrimination on account of economic status or source of payment and without delaying treatment for purposes of prior discussion of the source of payment unless such delay can be imposed without material risk to your health.
- You have the right to register a complaint against the Center by submitting a written complaint to the Center’s Clinical Director at the address below or by calling the Clinical Director at 508-833-8222. You should describe the specific nature of the complaint and provide your name and address. If the complaint is not resolved to your satisfaction, you have the right to file a grievance with the Massachusetts Department of Public Health concerning the physician, staff and/or the treatment you received at the Center. You can submit a written complaint to DPH’s Division of Health Care Quality at 99 Chauncey Street, Boston, MA 02111, or call 1-800-462-5540. The complaint form can be accessed on-line at http://www.mass.gov/eohhs/docs/dph/quality/healthcare/consumer-resident-patient-complaint-form.pdf. Medicare beneficiaries also have the right to contact the Office of the Medicare Beneficiary Ombudsman through the Centers for Medicare and Medicaid Services at http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/get-help-with-medicare-rights.html. The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive the information and help they need to understand their Medicare options and to apply their Medicare rights and protections.
- You have the right to exercise all of your rights without being subjected to discrimination or reprisal by the Center.
III. Patient Responsibilities – You are responsible for:
- Fully participating in decisions involving your healthcare. If legally authorized, another person can participate in medical decisions.
- Following your physician’s instructions, taking medications as prescribed and asking questions concerning your medical condition and/or planned procedure(s) as necessary.
- Providing complete and accurate health, medical and insurance information (including information about your prescription medications, over-the-counter medications, dietary supplements, allergies, sensitivities).
- Communicating changes in your health and/or condition to your health care providers.
- Fulfilling your financial obligations to the Center as promptly as possible.
- Accepting the consequences of refusing treatment or not following the treatment plan.
- Showing consideration for the rights of other patients and personnel in the Center.
- Following all of the Center’s policies and procedures.
- Providing a responsible adult to transport you home from the Center and to remain with you for 24 hours if required by your physician.
- Informing your physician about any health care proxy, living will, medical power of attorney, MOLST, or other directive that could affect your care.IV. Advance Directives Policy
- Advanced care planning is the process that some individuals undertake in preparation for receiving health care at the end of their lives. Each patient has a right to formulate such plans (Advance Directives) in accordance with Massachusetts law. In Massachusetts, advanced care planning tools include:
- Health Care Proxy: a legally binding document that allows you to name someone of your choice to make health care decisions for you in the event you are unable to make or communicate your own decisions.
- Living Will: a written statement of your wishes for medical treatment and end of life care in the event that you are unable to make healthcare decisions or communicate them directly. In Massachusetts, a Living Will provides evidence of your wishes, but it is not legally binding.
- Medical Order for Life-Sustaining Treatment (MOLST): a standardized form that contains medical orders for life-sustaining treatment based on a patient’s own preferences and goals of care and is signed by a physician, nurse practitioner or physician assistant. A MOLST is not designed for use by healthy individuals; rather, a MOLST is suitable for patients of any age with advanced illness, including, but not limited to life threatening disease or injury, chronic progressive disease, dementia or any patient suitable for a DNR order. In Massachusetts, a MOLST provides evidence of your wishes, but it is not legally binding; that is, a physician’s decision as to whether to honor the MOLST may be based on the physician’s clinical judgment and assessment of other relevant factors (e.g., patient’s current condition, competence, etc.).
- Comfort Care/DNR Order Verification Form/Bracelet: a method of extending your hospital-based DNR order so that it may be recognized outside of the hospital setting by EMTs and others who respond to emergencies. The Form/Bracelet provides evidence of your wishes, but it is not legally binding on non-emergency medical service personnel.
- An Advance Directive is not required in order to receive medical treatment at the Center. However, if you provide an Advance Directive to the Center, the Center will place such document(s) in your medical record.
- Although we respect your right to designate Advance Directives, it is the policy of the Center, at all times, to attempt to resuscitate, administer medical treatment to, and/or perform life-saving procedures on a patient, as needed, and transfer that patient to a hospital in the event of deterioration at an ambulatory surgery center, like the Center. The rationale for this policy is that life-threatening events or complications are rare when a patient is seeking care at an ambulatory surgery center for ophthalmic surgery, and the majority of those that do occur are almost always treatable. Therefore, the Center believes it would be unethical not to treat a patient who has experienced a life-threatening event or complication.
- In the event that you are transferred from the Center to a hospital, a copy of any Advance Directive you provided to the Center will be transferred to the hospital, together with the rest of your record.
- To learn more about Health Care Proxies, please visit http://www.malegislature.gov/Laws/GeneralLaws/PartII/TitleII/Chapter201D.
- To obtain a Massachusetts Health Care Proxy Form, please visit http://www.massmed.org/Patient-Care/Health-Topics/Health-Care-Proxies-and-End-of-Life-Care/Health-Care-Proxy-Information-and-Forms/.
- To learn more about a MOLST, please visit http://www.molst-ma.org/.
- To learn more about a Comfort Care/DNR Order Verification Form/Bracelet, please visit http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/oems/comfort-care/
Cape Cod Eye Surgery & Laser Center:
282 Route 130
Sandwich, MA 02563