82 Wind Chime Ct, Suite 201, Raleigh, NC 27615

919-848-1630 Fax 919-847-8635

STATEMENT OF PATIENT PRIVACY RIGHTS

As a home care patient, you have the privacy rights listed below.
You have the right to know why we need to ask questions.
We are required by law to collect health information to make sure:

1. You get quality care, and
2. Payment for Medicaid patients is correct.

You have the right to have your personal health care information kept confidential

You may be asked to tell us information about yourself so that we will know which home care services will be best for you.
We keep anything we learn about you confidential.
This means, only those who are legally authorized to know, or who have medical need to know, will see your personal health information.
You have the right to refuse to answer questions.
We may need your help collecting your health information.
If you choose not to answer, we will fill in the information the best we can.
You do not have to answer every question to get services.
You have the right to look at your personal information.

1. We know how important it is that the information we collect about you is correct.

If you think we made a mistake, ask us to correct it.

2. If you are not satisfied with our response, you can ask the Health Care Financing Administration or federal Medicaid agency, to correct your information.

You can ask the Health Care Financing Administration to see, review, copy or correct your personal health information which that federal agency maintains in its HHA System of Records.

CLIENT’S RIGHTS AND RESPONSIBILITIES

In the keeping with the philosophy of respect for the dignity of every person, we, the home care agency, believe the client has the following rights.
THE RIGHT – To be fully informed in advance orally or in writing about the care and treatment to be furnished by the home agency; of any changes in the care or treatment to be furnished that may affect the individual’s well-being and to participate in planning care and treatment or changes in care or treatment.
THE RIGHT – To voice grievance without discrimination or reprisal for voicing grievances with respect to the treatment or care that is furnished or fails to be furnished.
THE RIGHT – To confidentiality of the clinical records maintained by the home care agency. To have one’s property treated with respect. To be fully informed in advanced of coming under the care of the home care agency orally and in writing of:
THE RIGHT – To appropriate assessment and management of pain.
THE RIGHT – To choose whether or not to participate in research, investigational or experimental studies, or clinical trials.
THE RIGHT – To formulate advance directives.
THE RIGHT -To have their communication needs met. To privacy and security.

Grace Healthcare will respect the right of the patients.

To receive information about rights.
To refuse care, treatment, and services in accordance with law and regulation.
To personal dignity.
To have his or her cultural, psychosocial, spiritual, and personal values, beliefs, and personal preferences respected.
All items and services furnished by the home care agency for which pay merit may be made. The coverage available for items and services under Medicaid, and any other program of which the home care agency is reasonably aware. Any charges for items and service not covered under Medicaid and any charges the individual may have to pay regarding items and services furnished by the home care agency. Any changes in the charges or items and services for which the individual may by liable.
The availability of North Carolina department of Health HOTLINE for receiving Complaints and answering questions about the home care agency.
The number is 1-800-662-7030. The toll-free number’s hours of operation:
8AM to 5PM. Monday-Friday and after hours, weekends and holidays by answering machine. CLIENT’S RIGHTS AND RESPONSIBILITIES

CLIENT RESPONSIBILITIES

In keeping with the philosophy of respect for the dignity of every person, we, the home care agency, believe the client has the following rights.
In our efforts to provide a quality service and to protect the rights of each individual under our care, or clients in turn have the following responsibilities:
RESPONSIBILITY    For providing accurate and complete information about illness. Hospitalizations, medications, treatments, physician information and other pertinent health information.
RESPONSIBILITY   For participating in the development, implementation and updating of the care plan.
RESPONSIBILITY    For won action for refusing treatment or not following care established.
RESPONSIBILITY    For notifying the agency of the inability to keep home care visit.
RESPONSIBILITY    For communicating any concerns and problems to the home care agency.
RESPONSIBILITY    For providing accurate and complete information about Medicaid, or private insurance coverage.
RESPONSIBILITY     For financial obligation of charges for services or items not covered by Medicaid or private insurance.

As a patient of Grace Health Service in the state of North Carolina, you also have the right to:

• Be informed of the office policies and process for acceptance and continuance of service and eligibility determination.
• Be informed of the office on call system.
• Be informed of the accessibility and availability of office supervisory personnel.
• Be advised of the office procedure for discharge.
• Be informed of the staff member primarily responsible for your care, treatment and services upon admission.
• Be informed of the staff member (s) who will provide the care, treatment, and services upon admission and if reassignment of staff member (s) is warranted.

Grace Health Services, Inc

March 2015