Patient Bill of Rights and Responsibilities | Good Shepherd Rehabilitation

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Patient’s Bill of Rights

You have the right:

To receive care regardless of race, handicap, religion, sex, sexual orientation, gender identity, national origin, age or the source of payment for your care.
To be treated respectfully by others and to have your privacy and individuality
respected.
To express any spiritual belief or cultural practice that will not harm others and will not
interfere with the planned course of treatment you have agreed upon in the consultation
with your physician.
To know the names of the physicians who care for you and the right to receive an explanation
from your physicians, in terms you can understand, about the nature of your problem and the
course of treatment. If an operation is performed, you have the right to an explanation of
the operation in terms you can understand, its risks and consequences and any alternatives
available.
To refuse treatment or leave the medical center against your physician’s advice. You must
assume full responsibility for your decision.
To examine your bill and receive an explanation of your charges, regardless of the source
of payment.
To have your medical record maintained as confidential documents.
To give informed consent regarding your treatment.
To receive an explanation regarding your care following discharge.
To discuss with the physician, nurse or other health-care worker if you feel that you are not
being treated fairly or properly. You may also call or write the medical center administrator
to receive prompt and personal attention.

Patient’s Responsibilities

You are responsible for:

Being honest and direct about everything related to you as a patient.
Giving your physician accurate and complete information about your medical history.
Understanding your health problems to your own satisfaction. If you do not understand your
illness or treatment, ask your physician for clarification.
Being considerate of other patients and to see that your visitors are considerate as well.
Following medical center rules and regulations.
Your financial obligations to the medical center.
Respecting the rights of others and observing the medical center’s no-smoking policy.

Privacy Act Statement – Health-Care Records

This statement gives you notice required by law (The Privacy Act of 1974). This statement is not a consent form. It will not be used to release or to use your health-care information.

I. Authority for collection of your information, including your social security number and
whether or not you are required to provide information for this assessment. Sections
1102(a), 1154, 1861(z), 1864, 1865, 1866, 1871, 1886 (j) of the Social Security Act

Medicare participating inpatient rehabilitation facilities (IRF) must do a complete assessment that accurately reflects your current clinical status and includes information that can be
used to show your progress toward your rehabilitation goals. The IRF must use the Inpatient
Rehabilitation Facility-Patient Assessment Instrument (IFR-PAI) as part of that assessment, when evaluating your clinical status. The IFR-PAI must be used to assess every Medicare
Part A Fee-for-service inpatient, and it may be used to assess other types of inpatients.
This information will be used by the Centers for Medical and Medicaid Services (CMS) to
be sure that the IRF is paid appropriately for the services that they furnish you, and gives
appropriate health care to its patients. You have the right to refuse to provide information to the IRF for the assessment. Information provided to the federal government for this assessment is protected under the Federal Privacy Act of 1974 and the IRF-PAI System of Records. You
have the right to see, copy, and request correction of inaccurate or missing personal health information in the IRF-PAI System of Records.

II. Principal Purposes for which your information is intended to be used

The information collected will be entered into the IRF-PAI System No 09-70-1518. Your health care information in the IRF-PAI System of Records will be used for the following purposes:

Support the IRF prospective payment system (PPS) for payment of the IRF Medicare Part A
Fee-for-services furnished by the IRF to Medicare beneficiaries;
Help validate and refine the Medicare IRF-PPS;
Study and help ensure the quality of care provided by IRFs;
Enable CMS and its agents to provide IRFs with date for their quality assurance and ultimately
quality improvement activities
Support agencies of the state government, deeming organizations or accrediting agencies
to determine, evaluate, and assess overall effectiveness and quality of IRF services provided in the state;
Provide information to consumers to allow them to make better informed selections of providers;
Support regulatory and policy functions performed within the IRF or by a contractor/consultant;
Support constituent requests made to a Congressional representative;
Support litigation involving the facility;
Support research on utilization and quality of IRF services; as well as, evaluation or
epidemiological projects related to the prevention of disease or disability, or the restoration
or maintenance of health for understanding and improving payment systems

III. Routine Uses

These “routine uses” specify the circumstances when the Centers for Medicare & Medicaid Services may release your information from the IRF-PAI System of Records without your consent. Each
prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information. Disclosures of protected health information authorized by these routine uses may be made only if, and as, permitted or required by the ‘Standards for Privacy of Individually Identifiable Health Information.’ (45 CFR Parts 160 and 164. Disclosures of the information may be to:

Agency contractors or consultants who have been contracted by the agency to assist in the
performance of a services related to this system of records and who need to have access to the records in order to perform the activity;
To a Peer Review Organization (PRO) in order to assist the PRO to perform Title XI and Title
XVIII functions relating to assessing and improving IRF quality of care. PROs will work with IRFs
to implement quality improvement programs, provide consultation to CMS, its contractors and to State Agencies
To another Federal or State agency
a. To contribute to the accuracy of CM’s proper payment of Medicare benefits,
b. To enable such agency to administer a Federal health benefits program, or as necessary
to enable such agency to fulfill a requirement of a Federal statute or regulation that
implements a health benefits program funded in whole or in part with Federal funds, or
c. To improve the state survey process for investigation of complaints related to health and
safety or quality of care and to implement a more outcome-oriented survey and
certification program
To an individual or organization for a research, evaluation, or epidemiological projects
related to the prevention of disease or disability, the restoration or maintenance of health
epidemiological or for understanding and improving payment projects
To a member of Congress or to a congressional staff member in response to a inquiry of the
Congressional Office made at the written request of the constituent about whom the record
is maintained
To the Department of Justice (DOJ), court or adjudicatory body when:
a. The agency or any component thereof; or
b. Any employee of the agency in his or her official capacity; or
c. Any employee of the agency in his or her individual capacity where the employee; or
d. The United States Government; is a party of litigation or has an interest in such litigation,
and by careful review, CMS determines that the records are both relevant and necessary
to the litigation and the use of such records by the DOJ, court or adjudicatory body is
compatible with the purpose for which the agency collected the records
To a CMS contractor (including, but not necessarily limited to fiscal intermediaries and
carriers) that assists in the administration of a CMS-administered health benefits program, or to a grantee of a CMS-administered grant program, when disclosure is deemed
reasonably necessary by CMS to prevent, deter, discover, detect, investigate, examine,
prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud or abuse in such program.
To another Federal agency or to an instrumentality of any governmental jurisdiction within
or under the control of the US (including any State or local governmental agency), that
administers, or that has the authority to investigate potential fraud or abuse in whole or part
by Federal funds, when disclosure is deemed reasonable necessary by CMS to prevent, deter,
discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct,
remedy, or otherwise combat frauds or abuse in such programs;
To a national accrediting organization that has been approved for deeming authority for
Medicare requirements for IRF services (i.e., the Joint Commission for the Accreditation of
Health care Organizations, the American Osteopathic Association and the Commission of
Accreditation of Rehabilitation facilities). Data will be released to these organizations only
for those facilities that participate in Medicare by virtue of their accreditation status.
To insurance companies, 3rd party administrators (TPA), employers, self-insurers, manage care organizations, other supplemental insurers, non-coordinating insurers, multiple employer trusts, group health plans (i.e., health maintenance organizations (HMO) or competitive medical plan (CMP)) with a Medicare contract, or a Medicare-approved health care prepayment plan (HCPP), directly or through a contractor, and other groups of providing protection for their enrollees. Information to be disclosed shall be limited to Medi care entitlement data. In order to receive the information, they must agree to:
a. Certify that the individual about whom the information is being provided is one of its
insured or employees, or is insured and/or employed by another entity for whom they
serve as a 3rd party administrator;
b. Utilize the information solely for the purpose of processing the individual’s insurance
claims; and
c. Safeguard the confidentiality of the data and prevent unauthorized access.

IV. Effect on you if you do not provide information

The IRF needs the information contained in the IRF-PAI in order to comply with the Medicare
regulations. Your IRF will also use the IRF-PAI to assist in providing you with quality care. It is
important that the information be correct. Incorrect information could result in payment errors and could also make it difficult to evaluate if the facility is giving you quality services. If you choose not to provide information, there is no federal requirement for the IRF to refuse you services.

Contact Information

If you want to ask the Centers for Medicare and Medicaid Services to see, review, copy or
request correction of inaccurate or missing personal health information which that Federal agency maintains in its IRF-PAI System of Records:
Call 1-800-MEDICARE, toll free, for assistance in contacting the IRF-PAI System of Records Manager.
TTY for the hearing and speech impaired: 1-800-820-1202
This is a Medicare and Medicaid Approved Notice.

IMPORTANT MESSAGE FROM MEDICARE

Your Rights as a Hospital Inpatient:

You can receive Medicare covered services. This includes medically necessary hospital services and services you may need after you are discharged, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them.
You can be involved in any decisions about your hospital stay.
You can report any concerns you have about the quality of care you receive to your QIO at 1-888-396-4646. The QIO is the independent reviewer authorized by Medicare to review the decision to discharge you.
You can work with the hospital to prepare for your safe discharge and arrange for services you may need after you leave the hospital. When you no longer need inpatient hospital care, your doctor or the hospital staff will inform you of your planned discharge date.
You can speak with your doctor or other hospital staff if you have concerns about being discharged.

Your Right to Appeal Your Hospital Discharge:

You have the right to an immediate, independent medical review (appeal) of the decision to
discharge you from the hospital. If you do this, you will not have to pay for the services you
receive during the appeal (except for charges like copays and deductibles).
If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer also will
look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish.
If you choose to appeal, you and the reviewer will each receive a copy of a detailed explanation about why your covered hospital stay should not continue. You will receive this detailed notice only after you request an appeal.
If the QIO finds that you are not ready to be discharged from the hospital, Medicare will continue to cover your hospital services.
If the QIO agrees services should no longer be covered after the discharge date, neither Medicare nor your Medicare health plan will pay for your hospital stay after noon of the day after the QIO
notifies you of its decision. If you stop services no later than that time, you will avoid financial liability.
If you do not appeal, you may have to pay for any services you receive after your discharge date.

How to Ask for an Appeal of Your Hospital Discharge:

You must make your request to the QIO listed above.
Your request for an appeal should be made as soon as possible, but no later than your planned discharge date and before you leave the hospital.
The QIO will notify you of its decision as soon as possible, generally no later than 1 day after it receives all necessary information.

If You Miss the Deadline to Request An Appeal, You May Have Other Appeal Rights:

If you have Original Medicare: Call the QIO listed above.
If you belong to a Medicare health plan: Call your plan.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.