Sliding Fee Scale information and application can be downloaded from here - see the bottom of the page

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Notice of General Patient Rights and Privacy Practices

Effective Date:  March 29, 2004

Review Date:  March 1, 2011

Purpose This notice describes your rights as a patient at MOHC.  It also describes how health information about you may be used, disclosed, and how you can get access to this information.  Please review it carefully. 

Civil Rights

1. Patients have the right to considerate and respectful treatment in an environment free from harm.
2. Patients seeking services shall not be denied, suspended or terminated from services or have services reduced for exercising any of their rights.

Discrimination

1. Patients have the right to receive services regardless of age, sex, race, creed, color, religion, ethnic origin, ancestry, marital status, physical or mental disability, gender preference, veteran status or criminal record.
2. Patients may receive services without regard to one’s ability to pay; if you are unable to pay the full fee for services, a sliding fee scale is available to you.  You may examine and receive an explanation of your bill of services.
3. No recipient of services is presumed legally incompetent except as determined by a court.
4. Patients have the right to present any complaint or grievance on matters pertaining to services received, or any perceived or actual violation of rights.

Treatment

1. A recipient of services shall be provided with adequate and humane care and in the least restrictive environment, pursuant to an individualized service plan.  When appropriate, a recipient’s nearest kin or guardian shall be involved in the treatment/service plan.
2. Patients have the right to know of the variety of services that may be available and to participate in the planning of treatment.
3. Patients may refuse treatment at any time, and patients have the right to be informed of the consequences resulting from the refusal of treatment.

Confidentiality

1. Patients will receive confidential treatment; all clinical records and client information are protected by law, regulations and center policies.  For the purposes of funding, certification, licensure, audit, research or other legitimate purpose, your clinical record may be used by the person conducting the review to the extent that is necessary to accomplish the purpose of the review.
2. Patient information released to or requested from other sources requires your written consent.  Patient records can be subpoenaed by court order and does not require your signature for release of information.
3. Patients have the right to review, and obtain a copy of your clinical record in accordance with MOHC’s policy.

MOHC Responsibility

1. We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices.  We will abide by the terms of this notice.
2. In the case of suspected child abuse or neglect, MOHC is required by the Abused and Neglected Child Reporting Act to report any suspected incidents of neglect or abuse.  MOHC also has the ethical obligation to report suspected maltreatment of senior citizens or adults.
3. If at any time patients present a clear and present danger to yourself or to others, MOHC’s staff may release information that is required to protect you or others.
4. MOHC may restrict or terminate delivery of services to patients who have been evaluated and determined as posing a serious physical threat to staff or others.

If you have any concerns about patient privacy and your rights, please ask any staff member to contact the MOHC Director for assistance, or call (808) 553-4505.

INITIAL LIST OF CONTENT FOR THIS PAGE:

Intake process & financial policy Patient registration form (adult/child) Service agreement Eligibility Determination worksheet Sliding fee scale Payment options Appointment policy Privacy policy & patient bill of rights & responsibilities Notice of privacy practices Patient rights and responsibilities