As a patient at Stamford ASC, LLC, you have options for your care and treatment. Your doctors and other health care professionals will offer information and advice concerning appropriate, comprehensive medical care. At the same time, we realize that the stress of worry, concern and discomfort may interfere with your ability to understand important information or make decisions. As your caregivers, we will do our best to ensure a process that will enable you to make the decisions best for you, including the decision to discontinue treatment, to the extent permitted law.

It is the Center’s obligation and privilege to inform you of and explain (in a language your can understand), your rights and responsibilities as a patient, and assist you in exercising these rights.

Stamford ASC, LLC, has established written policies regarding your rights as a patient and has developed procedures implementing these policies. These rights, policies and procedures affirm the Center’s promise to uphold your rights as a patient, or when appropriate, your representative’s right to act on your behalf (as allowed under State law) to the following:

As a patient, you have rights which respect and honor:

1. The right to receive this notice entitled “Your Rights and Responsibilities” in advance of the Center furnishing your care. You also have the right to reasonable response to your requests and needs for treatment or service, within the Center’s capacity, its stated mission, and applicable law and regulation.
2. The right to considerate and respectful care regardless of race, creed, sex, national origin or source of payment. The patient’s care includes consideration of the psychosocial, spiritual and cultural variables that influence the perception of illness.
3. The right to participate in the development and implementation of your plan of care and treatment and make healthcare decisions in collaboration with your physician, including:
   • Your right to request, consent to accept and/or refuse care, treatment and services to the extent permitted by law (although this right cannot be construed as a mechanism for you to demand the provision of care, treatment or services deemed medically unnecessary or inappropriate), and the revealing of information regarding medical consequences of refusal of treatment.
   • The formulation of advanced directives, and the appointment of a surrogate to make healthcare decisions on your behalf to the extent permitted by law (you have the right to have the Center’s staff and practitioners who provide care in the Center comply with these directives subject to the limitations and requirements of applicable law).
4. The right to be informed of your health status and receive information necessary to enable you to make the extent permitted by law. This information shall include the possible risks and benefits of procedures and treatments and the outcomes of care even if unanticipated.
5. The right to receive information necessary to enable you to make a decision for an order not to resuscitate, and to appoint a surrogate to make a decision if the patient is too ill to do so, to the extent permitted by law.
6. The right to complain (verbally or in writing) to the facility’s staff directly or via the Center’s established grievance mechanism about the quality of care and services or any other matter without fear of reprisals. Concerns may also be addressed to the administrator, of the Center located at 200 First Stamford Place Stamford, CT 06902 phone: (203) 252-5400; the Connecticut Department of Public Health, located at 410 Capital Avenue, MS# 12HSR, Hartford, CT 06134-0308, phone: (860) 509-7400; webmaster.dph@ct.gov; or the Office of the Medicare Beneficiary Ombudsman, The U.S. Department of HHS, 200 Independence Ave, S.W., Washington, D.C.
7. The right to receive information, at the time of admission, about the Center’s patient rights policy and complaint response and resolution system.
8. The right to participate in the consideration of ethical issues that arise in the care of the patient (or the participation of the patient’s designated representative).
9. The right to receive information of any human experimentation or other research/education projects affecting your care or treatment.
10. The right to receive information about pain and pain relief measures and receive care from a concerned staff committed to pain prevention and management, health professionals who respond quickly to reports of pain, and dedicated pain relief specialists. You have the right to state-of-the-art pain management. Your reports of pain will be believed.
11. The right to personal privacy and confidentiality of information in accordance with current HIPPA privacy practices.
12. The right to access information contained in your medical record, within a reasonable time and within the limits of the law (or access by your legally designated representative). The right to request an itemized bill and explanation of all charges.
13. The right to be assured that the patient’s guardian, next of kin, or legally authorized responsible person, shall exercise, to the extent permitted by law, the rights delineated on behalf of the patient if the patient has been adjudicated incompetent in accordance with the law; is found by your physician to be medically incapable of understanding a proposed treatment or procedure; is unable to communicate your wishes regarding treatment, or, is a minor.
14. The right to have a family member or representative of your choice and your own physician notified promptly of your admission to the hospital.
15. The right to receive care in a safe setting, to be free from all forms of abuse or harassment, be free from restraints of any form that are not medically necessary.

Patient Responsibilities

1. Follow Center rules and regulations to help ensure the safety and comfort of all patients.
2. Respect other patient’s rights to privacy and quiet when using radio, TV and when having visitors.
3. Observe the no-smoking, clean-air Center policy.
4. Provide insurance information for processing bills, and assure that financial obligations are fulfilled as promptly as possible.
5. Ask your doctor or nurse what to expect regarding pain and pain management; discussing pain relief options with your doctors and nurses; work with your doctor and nurse to develop a pain management plan; ask for pain relief when pain first begins; help your doctor and nurse assess your pain; tell your doctor or nurse if your pain is not relieved; and tell your doctor or nurse about any worries you have about taking pain medication.

Financial Disclosure

Stamford ASC operatives this licensed outpatient surgical center (the “Center”) that provides various outpatient surgery services to our patients. As such, your physician may have an ownership interest in the center. We respect the rights of our patients to choose not only their surgeon but also where they wish to have their surgery. If you have any questions, concerns, or issues related to the ownership of the facility, please discuss them with your physician or contact our facility administrator.

Advanced Directive

In the state of Connecticut, all patients have the right to participate in their own health care decisions. Patients may create an Advance Directive or other document authorizing a third party to act on their behalf in the event that a patient is unable to communicate a decision about care. The nature of our healthcare practice is one focused on expected outcomes regarding non-emergency procedures on those individuals whose medical condition is stable and who are prepared for this plan of management. Therefore, if you have an Advanced Directive, it is our policy that if an adverse event occurs during your treatment at Stamford ASC, we will initiate resuscitative or other stabilizing measures and transfer you to a higher care facility for further evaluation. Your agreement with the Center policy will not revoke or invalidate any current health care directive.

On the day of surgery you will be asked to check off one the following:

• I do not have an Advance Directive.
• I do not have an Advance Directive but would like some information about creating one.
• I have an Advance Directive and have brought it with me today to provide to the facility. The facility will put it in my medical records and that document will follow me throughout my course of care.
• I have created an Advance Directive but did not bring it with me today. I will make every effort to provide a copy to this facility.

For more information on making informed decisions about end-of-life care and services, you may contact the State of Connecticut Attorney General at 860-808-5318 or http://ct.goc/ag/lib/ag/health/advdirectivescombinedform2006alt.pdf.

If you do not agree with Stamford ASC policy, we will be pleased to assist you in transferring to a provider who is willing to comply with your wishes.