Privacy & Patient Rights

Center Ownership

Four Women Health Services and its investors recognize that they are required to disclose to its patients and the public the owner(s) of the Center

1. The Four Women brochure will list all investors in the Center. The brochure will be provided to all members of the medical staff to be distributed to the patients at the time they are scheduled for surgery.
2. Each Investor will annually be reminded that they are to notify patients that they have ownership in the ambulatory surgery center.
3. Four Women Health Services is owned by Marcus Gordon, MD.
4. Current ownership and/or changes in ownership of the center, including specific physician, hospital or corporate investors will be provided to CMS, state licensing bodies and/or other required agencies.

Advance Directives

To provide a method for patients to provide written or oral instructions about her future medical care, in the event that she becomes unable to communicate those instructions herself.

Under the Health Care Proxy Law (Massachusetts General Laws, Chapter 201D), any competent adult 18 years of age or over may use the Health Care Proxy form to appoint a Health Care agent. Resources for completing this form are contained in a binder in the waiting room for all patients to access.

Patient Rights and Responsibilities

As a patient of Four Women Health Services, or as the parent or guardian of a minor patient at Four Women, we want you to know the rights that you have under federal and Massachusetts state law.

Your rights

Respect

You have the right to:

• receive health care that respects your cultural, psychosocial, and personal values and beliefs. Four Women is committed to serving all patients, without regard to race, color, religion, national origin, sex, age, marital status, sexual orientation, gender identity or expression, disability, political affiliation, veteran status, or other non-medically relevant factors.
• obtain a copy of any rules or regulations that relate to the conduct of patients, as provided below.

Privacy and confidentiality

You have the right to:

• know that your records and communications are confidential to the extent provided by law.
• expect privacy during medical treatment and care, within the capacity of Four Women.

Participation

You have the right to:

• refuse to be examined, observed, or treated by students or other Four Women staff, without jeopardizing access to medical care.
• refuse to serve as a research subject or receive any care or examination that is primarily for educational or informational purposes, rather than for treatment.
• participate in any consideration of ethical issues that arise in your care or your child’s, such as resolving conflict, withholding resuscitation, forgoing or withdrawing life-sustaining treatment, or taking part in research studies.

Pain management

You have the right to:

• receive assessment and treatment for physical and psychological pain.

Information and treatment

You have the right to:

• obtain an explanation of any relationship (including financial) Four Women, or your physician, has with another health-care facility or educational institution, to the extent that the relationship relates to your care or your child’s.
• receive information regarding financial assistance or free health care.
• obtain the name and specialty of the physician or other health-care providers caring for you or your child.
• have all reasonable requests responded to promptly and adequately within the capacity of Four Women.
• receive enough information to give an informed consent to treatment, to the extent provided by law, including an explanation of your condition or your child’s, proposed treatments, and alternative therapies, with their respective benefits and risks.
• make decisions regarding your health care, including the decision to refuse or discontinue treatment, to the extent permitted by law.
• fill out advance care directives in Patient Portal, such as a health care proxy form to designate someone who can make decisions for you, if you become incapable of understanding a proposed treatment or procedure, or are unable to communicate your wishes regarding care.
• receive a complete copy of the Massachusetts Patient Rights law (M.G.L. chapter 111 section 70E), available on the Internet at http://www.mass.gov/legis/laws/mgl/111-70e.htm.
• inspect your medical record, or your child’s, and receive a copy of it. If you request a copy, you may be charged a fee, unless you show that your request supports a claim or appeal under any provision of the Social Security Act in any federal or state needs-based benefit program.
• receive prompt, life-saving treatment in an emergency without discrimination or delay based on economic or payment concerns.
• receive a prompt and safe transfer to the care of others if Four Women is unable to meet your request or need for treatment or service. For example, if we are unable to offer the type and quality of care, based on available resources, required by your specific condition or disease, or those of your child, we will make sure that you can receive care elsewhere.
• receive an itemized list of charges submitted by Four Women to your insurer or another third party regarding your care or your child’s, including the amounts covered by the third-party payer, and a copy of Four Women’s itemized charges sent to the attending physician.
• register complaints or grievances, and seek solutions to problems. You have the right to file a grievance with Four Women if you have concerns regarding your care and treatment.

Your responsibilities

• By taking an active role in your health care, you can help your caregivers meet your needs as a patient or family member. That is why we ask you and your family to share certain responsibilities with us.

We ask that you:

• provide, to the best of your ability, accurate and complete information about your present condition, past illnesses, hospitalizations, medications, and other matters related to your health or your child’s, including information about home and/or work that may impact your ability to follow the proposed treatment.
• follow the treatment plan developed with your provider. You should express any concerns about your ability to comply with a proposed course of treatment. You are responsible for the outcomes if you refuse treatment or do not follow your care provider’s instructions.
• be considerate of other patients and Four Women staff and their property. Abusive, threatening. or inappropriate language or behavior will not be tolerated.
• keep appointments or call us when you are unable to do so.
• be honest about your financial needs, so that we may connect you to appropriate resources.
• give us any health care proxy or other legal document, such as a power of attorney or court order, that may affect your decision-making ability or care.
• notify us if you object to students or researchers participating in your care.

Please direct your concerns to:

Four Women Health Services, Attention Clinic Manager
150 Emory Street
Attleboro, MA 02703
Phone: (508) 222-7555
Fax: (508) 226-2218

Massachusetts Department of Public Health
Division of Health Care Quality
99 Chauncy St., 2nd Floor
Boston, MA 02111
Phone: (800) 462-5540
Fax: (617) 753-8165 Massachusetts Board of

Registration in Medicine
200 Harvard Mill Square, Suite 330
Wakefield, MA 01880
Phone: (800) 377-0550
Fax: (781) 876-8383