OHIO VALLEY ASC

During your preoperative phone call from our Centers' nurse, you will verbally be given the information contained in this brochure and you will be asked if you have received a written copy of this information. Advance Directive An advance directive speaks for you if you are unable to speak and helps to assure that your religious and personal beliefs will be respected. It is a useful document for an adult of any age to plan for future health care needs. Although Ohio Valley Ambulatory Surgery Center do not honor advance directives, upon request we will provide you with contact information and forms to assist in writing an advance directive. Grievances and Grievance Procedures We strive to maintain a professional and compliant atmosphere. Issues can arise. The Grievance procedure is a means for patients and related parties to inquire into issues raised and identify whether action needs to be taken to resolve identified issues and prevent recurrence. The Facility Administrator will record the grievance complaint and conduct a prompt investigation for quick resolution. Any patient and/or support person, visitor, employee, physician, or vendor may lodge a grievance using the Center’s procedure to formally voice complaints, resolve disputes, or to bring attention to possible violations of patient rights. No person shall be punished or retaliated against for using the Grievance Procedure. Any grievances, comments and complaints are addressed to the Center Administrator. Complete details and a copy of the Center’s Grievance Policy as well as a Grievance form may be obtained by contacting Erin Metz, the Center's Administrator at 740.423.4684 or P.O. Box 369, Belpre, OH. 45714 or

erin@ohiovalleyasc.com

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 advice, 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.

Additional information can be obtained from or to file a complaint with the State of Ohio contact:

Ohio Department of Health Consumer Complaint, Publication and Information Call Center, ODH, PCSU, 246 N. High Street, Columbus, OH. 43215

800.342.0553

www.HCComplaints@odh.ohio.gov

800.MEDICARE - 800.633.4227

If you have any questions or comments, please contact Erin Metz, the Center's Administrator at 740.423.4684.

Ohio Valley Ambulatory Surgery Center

608 Washington Boulevard • Belpre, OH 45714

P: 740.423.4684 • F: 740.423.4694 • eMail: info@ohiovalleyasc.com

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