You have the right to:

1. Care and treatment in accordance with your medical needs, and that is respectful and considers your dignity, cultural values, and religious beliefs, including the right to wear personal clothing or religious, cultural, or other symbolic items that do not interfere with treatment or procedures.

2. Have an Advance Directive (such as a “Living Will” or similar document) and name the person of your choice to make health care decisions on your behalf, to the extent permitted by law, and to have that person, a friend or family member, and/or your physician promptly notified of your admission to Memorial.

3. Communicate with individuals outside of Memorial.

4. Visual and, as appropriate, auditory privacy, and to receive care in a safe and clean environment.


5. Confidentiality of your medical information, in accordance with state and federal laws and regulations. If you feel that your health information has not been maintained securely or confidentially, you may report your concerns to:
   

   
   

   Privacy Officer: 719-365-2309
   

   Compliance Specialist: 719-365-2322
   

   Patient Representatives: 719-365-5621
   

   
   

   Or you may send a letter to: Memorial Health System, Attn: Privacy Officer, 1400 E. Boulder St., Colorado Springs, CO 80909
   

   
   

6. Participate in decisions regarding your care in a manner that is consistent with state and federal laws and regulations.

7. Receive information about your treatment in the language you understand, or have the information interpreted in a language you understand.

8. 
Receive information related to care and treatment so that you may make an informed decision whether to consent to a treatment. The information about your treatment should be provided by the treating physician. Consent to treatment may be given by you or your legal representative.
   

   
   

   In order to give informed consent, you will be provided with an explanation to include:
   

   
   

   a.) Recommended treatments or procedures, in terms you understand.
   

   b.) The treatment alternatives available and the risks and benefits of each alternative, mortality risks, prognosis, serious side-effects, and the consequences if you decide not to undergo any treatment.
   c.) The nature of recovery, anticipated problems, or potential problems that may occur during recovery, and the anticipated length of recuperation.

   d.) That either you or your legal representative may withdraw consent and discontinue participation in treatment.
   

   
   

9. Freedom from all forms of abuse, including mental, physical, sexual, verbal, and neglect or exploitation.
10. 
Freedom from restraints of any form that are not medically necessary.
11. 
A commitment to the prevention and management of pain by Memorial’s medical and nursing staff, consistent with state and federal laws and regulations.
12. 
Refusal of any drug, test, treatment or procedure, consistent with state and federal statutes, including being informed of the likely medical consequences of such refusal.

13. 
Promote your own safety by reminding any member of Memorial’s staff to:
    

    
    

    a.) Verify, prior to any procedure, the site or side of your body to be treated or operated on.
    

    b.) Check your ID before medication or blood is given.
    

    c.) Wash her or his hands prior to giving care.
    

    d.) Tell you why a procedure is being performed, or a medication is being given.
    

    
    

14. 
Information about Memorial’s grievance procedure. A patient representative may be reached directly by dialing 719-365-5621.
15. 
The right to file a grievance with: The Colorado Department of Public Health and Environment, 4300 Cherry Creek Dr. South, Denver, CO 80246 303-692-2800. Alternatively, if patient safety or care quality concerns have not been addressed, you may contact The Joint Commission at 1-800-994-6610. You may also contact the Colorado Department of Regulatory Agencies at (303) 894-7855 or toll free at (800) 886-7675. 

16. Know the names, professional status and experience of staff providing care or treatment.

17. 
Be informed about Memorial’s general billing procedures:
    

    
    

    a.) Prior to the initiation of non-emergency treatment, upon request, you have the right to be informed of routine, usual or customary charges or estimated charges for service based on an average patient with a diagnosis similar to your tentative admission diagnosis.
    

    b.) If you have questions, you may call 719-365-2138 for medical cost information, Monday through Friday, 8 a.m. to 5 p.m.
    

    c.) Based on the insurance information you provide, Memorial will provide assistance, as needed, with estimates of co-payments, deductibles, or other charges you owe. You may obtain assistance by calling Patient Financial Services at 719-365-5242, Monday through Friday, 8 a.m. to 5 p.m.
    

    d.) An itemized bill, in accordance with state and federal regulations.

    

    
    

18. Consent or refuse to take part in teaching activities, medical research where required by IRB, or any experimental projects related to your care, regardless of whether your care is provided by a physician, podiatrist, or dentist. 

19. Access your medical records in a manner consistent with state and federal laws. Contact Health Information Management at 719-365-5275.

20. Be accepted for ongoing treatment on the basis of a reasonable expectation that your medical, nursing, and other health care needs can be met adequately at Memorial.

21. Disclosure as to whether referrals are to providers in which Memorial has a financial interest.   

22. Choose your post-hospital care provider. As part of the discharge planning process, Memorial will not specify or limit any qualified agency that may provide post-hospital home health care or other services in compliance with the Patient Choice Law. Memorial staff will provide information about care providers or available services.

You have the responsibility to:

1. Provide Memorial with accurate and complete information about your present complaints and medications, and about your past health history.

2. Provide Memorial with accurate information about your current insurance coverage and/or eligibility for state or federal programs, and fulfill your financial obligations to Memorial.

3. Be considerate of the rights of others at Memorial, and to follow Memorial’s rules about controlling noise, tobacco use, number of visitors and unauthorized photography/videography.

4. Respect the belongings of others and Memorial property.

5. Indicate whether or not you understand a contemplated course of treatment so that you may make an informed decision regarding the treatment. 

6. Immediately inform your physician or Memorial staff that language interpretation is required in order for you to understand and provide informed consent regarding your care and treatment. 

7. Report to your health care providers any unexpected changes in your medical condition.

8. Ask questions when you do not understand information or instructions.

9. Follow Memorial’s instructions affecting your care.