Welcome to Crystal Clinic.
Crystal Clinic is nationally-renowned for delivering unparalleled patient outcomes. With multiple locations throughout Northeast Ohio, our physician-owned hospital system provides breakthrough orthopaedic, plastic, and reconstructive care and, most importantly, restores lives. Our world-class orthopaedic physicians are at the forefront of developing many of these breakthroughs using leading-edge technologies and procedures to advance orthopaedic care in spine, hip, knee, hand and wrist, foot and ankle, and shoulder.
Our elite plastic and reconstructive group is the largest and most experienced in the region. Crystal Clinic Plastic Surgeons provides comprehensive care from complex reconstruction to cosmetic and non-invasive procedures, including post-mastectomy breast reconstruction and facial reanimation.
In addition to outstanding care at our clinics, you have access to numerous other specialties including pain management, physical medicine and rehabilitation, physical and hand therapy, and advanced imaging services.
We are known for having one of the world’s most advanced state-of-the-art hospitals dedicated exclusively to orthopaedics and plastic/reconstructive care. This hospital, as well as our outpatient surgery center, is centrally located to all of our clinics.
In cases where you may need immediate care for orthopaedic injuries such as breaks, strains and pains, Crystal Clinic QuickCare™ locations are available to you without an appointment. Whether you are a new or returning patient, we are pleased to provide you with unmatched, compassionate care. We are here to help you get back to activities you love most, stronger than ever.
Thank you for entrusting us with your care.
The entire staff of healthcare professionals at Crystal Clinic
We Hope We Exceed Your Expectations to Earn Your Five-Star Rating.
As a physician-owned hospital system, our patients are always our first priority. We strive to exceed your expectations by delivering nationally-renowned care and unparalleled patient outcomes.
Following your visit at Crystal Clinic, you may receive a request to review your experience. Please take a moment to complete the survey and let us know how we did in delivering you five-star care. You and your feedback are very important to us.
Thank you from your Crystal Clinic care team.
Our commitment to our patients is to provide comprehensive orthopaedic care in a safe, comfortable environment for you and your family. We are proud that many of the physicians that practice here have chosen to have ownership in the Crystal Clinic Orthopaedic Center. Our physician partners play an active leadership role in fulfilling our commitment to you. Please carefully review the information contained in this notice so that you can make an informed decision regarding your care. The CCOC supports initiatives that provide transparency in healthcare. We believe that corporate compliance, ethics, and integrity are essential elements in any healthcare organization. With the rising costs of healthcare, Americans are interested in physician, hospital, insurance company, supplier, and any other industry relationships. As such, we have chosen to make certain disclosures to the public on arrangements that may be perceived as conflicts of interest.
According to Federal Regulations, Crystal Clinic Orthopaedic Center meets the definition of a “physician-owned hospital” under 42 CFR 489.3. The hospital is owned, in part, by physicians who may be providing your care. A list of those physicians will be provided upon request. You have the right to choose the provider of your health care services. Although we believe that Crystal Clinic Orthopaedic Center will be able to meet your needs, you have the option to use a facility other than Crystal Clinic Orthopaedic Center. You will not be treated differently by your physician if you choose to use a different facility; however, your physician may not be able to perform your procedures at an alternative facility if he or she does not maintain privileges at that facility. If desired, your physician or another staff member can provide information about the alternative health care providers.
If you have any questions concerning this notice, please feel free to ask your physician or any representative of Crystal Clinic Orthopaedic Center. We welcome you as a patient and value our relationship with you.
As a patient or as a family member or guardian of a patient at Crystal Clinic Orthopaedic Center, we want you to know the rights you have under federal and state law as soon as possible in your hospital stay. We are committed to honoring your rights and encourage you to take an active role in your health care. That is why we ask that you and your family share with us certain responsibilities.
Access to Care
- As a patient you have the right to receive care without discrimination due to age, sex, race, color, religion, sexual orientation, income, education, national origin, marital status, culture, language, disability, or source of payment for care.
- To avoid compromising Crystal Clinic Orthopaedic Center’s quality of care, clinical decisions (including tests, treatments and other interventions) are based on identified patient healthcare needs regardless of how the hospital compensates its employees or clinical staff.
- You will receive services and care that are medically suggested and within the hospital’s services, its stated mission, and required laws and regulations.
You have the right to:
- Expect emergency procedures to be implemented without unnecessary delay.
- Receive care in a safe setting free from any form of abuse, harassment, and neglect.
- Receive kind, respectful, safe, quality care delivered by skilled staff.
- Know the names and professional status of doctors and nurses providing care to you and the names and roles of other health care workers and staff that are caring for you.
- Know which physician or other practitioner is primarily responsible for your care.
- Request a consultation by another healthcare provider.
- Receive care free from restraints or seclusion unless necessary to provide medical, surgical, or behavioral healthcare.
- Receive efficient and quality care with high professional standards that are continually maintained and reviewed.
You have the right to:
- Decide if you want visitors or not while you are here. The hospital may need to limit visitors to better care for you or other patients.
- Designate those persons who can visit you during your stay. These individuals do not need to be legally related to you.
- Designate a support person who may determine who can visit you if you become incapacitated.
You have the right to:
- Have a family member, or another person that you choose, notified when you are admitted to the hospital.
- Receive information in a way that you can understand. This includes interpretation and translation, free of charge, in the language you prefer for talking about your healthcare. This also includes providing you with needed help if you have vision, speech, hearing, or cognitive impairments.
- Designate a support person, if needed, to act on your behalf to assert and protect your patient rights.
CONFIDENTIALITY AND PRIVACY
You have the right to:
- Limit who knows about your being in the hospital.
- Be interviewed, examined, and discuss your care in places designed to protect your privacy.
PLAN OF CARE
You have the right to:
- Receive a medical screening exam to determine treatments.
- Participate in the care that you receive in the hospital.
- Receive instructions on follow-up care and participate in decisions about your plan of care after you are out of the hospital.
- Receive a prompt and safe transfer to the care of others when this hospital is not able to meet your request or need for care or service. You have the right to know why a transfer to another healthcare facility might be required, as well as learning about other options for care. The hospital cannot transfer you to another hospital unless that hospital has agreed to accept you.
- Be informed by the responsible practitioner or his delegate of any continuing healthcare requirements following discharge from the hospital.
- Receive proper assessment and management of pain, including the right to request or reject any or all options to relieve pain.
You have the right to:
- Review, obtain, request, and receive a detailed explanation of your hospital charges and bills in accordance with Ohio laws and regulations.
- Receive information and counseling on ways to help pay for the hospital bill.
- Request information about any business or financial arrangements that may impact your care.
COMPLAINTS AND CONCERNS
You and your family/guardian have the right to:
- Tell hospital staff about your concerns or complaints regarding your care. This will not affect your future care.
- Make a complaint or voice a concern directly to Crystal Clinic Orthopaedic Center by calling the Patient Liaison at 330-670-6144.
- Expect a timely response to your complaint or grievance from the hospital. The hospital has a duty to respond to these complaints or grievances in a manner that you can understand.
- Lodge a complaint with the Ohio Department of Health and/or The Joint Commission at the following addresses or phone numbers:
You can reach the Ohio Department of Health by calling 800-342-0553
The Ohio Department of Health Complaint Unit
246 North High Street, Columbus, OH 43215
You can reach The Joint Commission, a hospital accreditation
organization, at :
The Joint Commission – Office of Quality Monitoring
One Renaissance Boulevard; Oakbrook Terrace, IL 60181
800-994-6610 or firstname.lastname@example.org
Medicare Beneficiaries Only:
Attention to: BFCC-QIO Program
10820 Guliford Road, Suite 202; Annapolis Junction, MD 20701
800-425-9900 TTY: 888-985-8775
ADVANCE DIRECTIVES AND ETHICS
You have the right to:
- Create advance directives, which are legal papers that allow you to decide now what you want to happen if you are no longer healthy enough to make decisions about your care.
- Ask about and discuss the ethics of your care, including resolving any conflicts that might arise such as deciding against, withholding, or withdrawing life-sustaining care.
As a patient, family member, or guardian, you have the right to know all hospital rules and what we expect of you during your hospital stay.
- Be advised why certain people are present and to ask others to leave during sensitive talks or procedures.
- Expect all communications and records related to care, including who is paying for your care, to be treated as private.
- Receive written notice that explains how your personal health information will be used and shared with other healthcare professionals involved in your care.
- Review and request copies of your medical record unless restricted for medical or legal reasons in accordance with Ohio laws and regulations.
You have the right to:
- Receive information about your current health, care, outcomes, recovery, ongoing healthcare needs, and future health status in terms that you understand.
- Be informed about proposed care options including the risks and benefits, other care options, what could happen without care, and the outcome(s) of any medical care provided, including any outcomes that were not expected. You may need to sign your name before the start of any procedure and/or care. “Informed consent” is not required in the case of an emergency.
- Be involved in all aspects of your care and to take part in decisions about your care.
- Make choices about your care based on your own spiritual and personal values.
- Request care. This right does not mean you can demand care or services that are not medically needed.
- Expect the hospital to get your permission before taking photos, recording, or filming you, if the purpose is for something other than patient identification, care, diagnosis, or therapy.
- Decide to take part or not take part in research or clinical trials for your condition, or donor programs that may be suggested by our doctor. Your participation in such care is voluntary, and written permission must be obtained from you or your legal representative before you participate. A decision to not take part in research or clinical trials will not affect your right to receive care.
- Refuse any care, therapy, drug, or procedure against the medical advice of a doctor to the extent permitted by law. When refusal of treatment by you or your legally responsible party prevents the provision of appropriate care in accordance with ethical and professional standards, the relationship with the patient may be terminated upon reasonable notice.
- Know of the existence of any professional relationship among individuals who are treating you, as well as the relationship of the hospital to any other healthcare or educational institution involved in your care
As a patient, family member, or guardian, we ask that you:
- Provide accurate and complete information about current healthcare problems, past illnesses, hospitalizations, medications, and other matters relating to your health.
- Report any condition that puts you at risk (for example, allergies, hearing problems or history of falls).
- Report unexpected changes in your condition to the healthcare professionals taking care of you.
- Provide a copy of your Advance Directive, Living Will, Durable Power of Attorney for Health Care, and any organ/tissue donation permissions to the healthcare professionals taking care of you.
- Tell us who, if any, visitors you want during your stay.
- Inform us of any assistive devices you use for hearing, ambulating, and/or seeing.
RESPECT AND COLLABORATION
As a patient, family member, or guardian, we ask that you:
- Respect the rights of other patients, families, and staff. Threats, violence, or harassment of other patients and hospital staff will not be tolerated.
- Comply with the hospital’s no smoking policy.
- Refrain from conducting any illegal activity on hospital property. If such activity occurs, the hospital will report it to the police.
- Follow the care plans suggested by the healthcare professionals caring for you while in the hospital. You should work with your healthcare professionals to develop a plan that you will be able to follow while in the hospital.
- Discuss your discharge instructions or plan with your doctor or nurse prior to discharge. Ask when you are to visit your doctor and if you need to call their office for test results.
As a patient, family member, or guardian, we ask that you:
- Promote your own safety by becoming an active, involved, and informed member of your healthcare team.
- Ask questions if you are concerned about your health and safety.
- Make sure your doctor knows the site/side of the body that will be operated on before a procedure.
- Remind staff to check your identification using your full name and date of birth before medications are given, blood/blood products are administered, blood samples are taken, or before any procedure or test.
- Remind caregivers to wash their hands before taking care of you.
- Be informed about which medications you are taking and why you are taking them.
- Ask all hospital staff to identify themselves.
- Know your surroundings and remember to ask for assistance to avoid falls.
As a patient:
- You are responsible for your actions if you refuse care or do not follow care instructions.
As a patient:
- You are responsible for paying for the healthcare that you received as promptly as possible.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices apply to Crystal Clinic Orthopaedic Center, Crystal Clinic Inc., any entities or facilities owned by or affiliated with Crystal Clinic Orthopaedic Center and the Medical Sta and their dependent practitioners (collectively referred to as“Crystal Clinic Orthopaedic Center”). These entities and people operate together as a clinically integrated health care arrangement. This clinically integrated health care arrangement includes our main facility and remote offices, and all of our programs, services, departments and units within our health care facilities. Crystal Clinic Orthopaedic Center is made up of many people such as our doctors, physician assistants, nurses, therapists, specialists, other health care professionals permitted by us to provide services to you, and staff, students, residents, trainees, volunteers and others involved in providing your care and services. These entities and people will share personal, protected health information of patients as necessary to carry out treatment, payments and health care operations as permitted by law.
Crystal Clinic Orthopaedic Center is required by law to maintain the privacy of our patients’ personal, protected health information and to provide patients with notice of our legal duties and privacy practices with respect to your personal, protected health information. We are required to notify you if there is a breach of your unsecured protected health information. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all personal, protected health information maintained by us. You may receive a copy of any revised Notice at any Crystal Clinic Orthopaedic Center point of registration or a copy may be obtained by mailing a request to the Privacy Officer of Crystal Clinic Orthopaedic Center at 3925 Embassy Parkway, Suite 250, Akron, OH 44333.
USES AND DISCLOSURES OF YOUR PERSONAL,
PROTECTED HEALTH INFORMATION
Your Authorization. Except as outlined below, we will not use or disclose your personal, protected health information for any purpose unless you have signed a form authorizing the use or disclosure. Most uses and disclosures of your health information for marketing purposes and disclosures that constitute a sale of your health information require your authorization. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.
Uses and Disclosures for Treatment. We will make uses and disclosures of your personal, protected health information as necessary for your treatment. For instance, doctors, nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, tests, etc. We may also release your personal, protected health information to another health care facility or professional who is not affiliated with our organization but who is or will be providing treatment to you. For instance, if, after you leave the surgery center, you are going to receive home health care, we may release your personal, protected health information to that home health care agency so that a plan of care can be prepared for you. We may also participate in electronic health information exchanges that facilitate access to personal, protected health information by other health care providers who provide you care. For example, if you receive care from another provider that participates in the health information exchange, this exchange will allow us to make your personal, protected health information available to the provider as needed for your treatment.
Appointments and Services. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal, protected health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders not to be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing and may send your request to the Privacy Officer of Crystal Clinic Orthopaedic Center at 3925 Embassy Parkway, Suite 250, Akron, OH 44333.
Health Products and Services. We may from time to time use your personal, protected health information to communicate with you about health products and services necessary for your treatment, to advise you of new products and services we offer, and to provide general health and wellness information.
Research. In limited circumstances, we may use and disclose your personal, protected health information for research purposes. For example, a researcher may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board that oversees the research, or by representations of the researchers that limit their use and disclosure of patient information.
Other Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your personal, protected health information without your authorization. We may release your personal, protected health information:
- for any purpose required by law;
- for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;
- as required by law if we suspect child abuse or neglect; we may also release your personal, protected health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
- to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;
- to your employer when we have provided health care to you at the request of your employer; in most cases you will receive notice that information is disclosed to your employer;
- if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
- if required to do so by a court or administrative ordered subpoena or discovery request; in most cases you will have notice of such release;
- to law enforcement officials as required by law to report wounds and injuries and crimes;
- to coroners and/or funeral directors consistent with law;
- if necessary to arrange an organ or tissue donation from you or a transplant for you;
- if you are a member of the military as required by armed forces services; we may also release your personal, protected heath information if necessary for national security or intelligence activities;
- to workers’ compensation agencies if necessary for your workers’ compensation benefit determination.
RIGHTS THAT YOU HAVE
Access to Your Personal, Protected Health Information. You have the right to receive a copy and/or inspect much of the personal, protected health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. We will charge you a reasonable fee if you request a copy of the information. We may also charge for postage if you request a mailed copy. Patients or their legal representatives may request access to their personal, protected health information by completing the Authorization for Release of Information Form. This Form is available from Health Information Management or the Patient Accounts Department.
Uses and Disclosures for Payment. We will make uses and disclosures of your personal, protected health information as necessary for the payment purposes of those health professionals and facilities that have treated you or provided services to you. For instance, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you or we may use your information to prepare a bill to send to you or to the person responsible for your payment.
Uses and Disclosures for Health Care Operations. We will use and disclose your personal, protected health information as necessary and as permitted by law, for our health care operations that include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal, protected health information for purposes of improving the clinical treatment and care of our patients. We may disclose protected health information to doctors, nurses, technicians, medical students, volunteers and other persons for review and learning purposes and for the operation of educational programs. We may also disclose your personal, protected health information to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with you.
Our Patient Directory. Crystal Clinic Orthopaedic Center maintains a patient directory listing the name, room number, general condition and, if you wish, your religious affiliation. Unless you choose to have your personal, protected health information excluded from this directory, the information, excluding your religious affiliation, will be disclosed to anyone who requests it by asking for you by name. This information, including your religious affiliation, may be also provided to members of the clergy. You have the right during registration to have your information excluded from this directory.
Family and Friends Involved in Your Care. With your approval, we may disclose your personal, protected health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited personal, protected health information with such individuals without your approval. We may also disclose limited personal, protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations such as auditing, accreditation, legal services, etc. At times it may be necessary for us to provide some of your personal, protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
Fundraising. We may contact you to donate to a fundraising effort for or on our behalf. You have the right to“opt-out”of receiving fundraising materials or communications and may do so by sending your name and address to the Privacy Officer of Crystal Clinic Orthopaedic Center at 3925 Embassy Parkway, Suite 250, Akron, OH 44333 together with a statement that you do not wish to receive fundraising materials or communications from us.
Amendments to Your Personal, Protected Health Information. You have the right to request in writing that personal, protected health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request. If we make an amendment or correction that you request, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. Amendment request forms may be obtained from Health Information Management.
Accounting for Disclosures of Your Personal, Protected Health Information. You have the right to receive an accounting of certain disclosures made by us of your personal, protected health information after May 2009. Requests must be made in writing and signed by you or your representative. Accounting request forms are available from Health Information Management. The first accounting in any 12-month period is free; you will be charged a reasonable fee for each subsequent accounting you request within the same 12-month period.
Restrictions on Use and Disclosure of Your Personal, Protected Health Information. You have the right to request restrictions on certain uses and disclosures of your personal, protected health information for treatment, payment, or health care operations by contacting the Privacy Officer. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate. There is one exception: We must agree to your restriction request if you ask us not to disclose information related to a health care item or service to your health plan for the purposes of payment or health care operations when you have paid for the health care item or service out of pocket in full. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing, any agreed-to restriction by sending such termination notice to the Privacy Officer of Crystal Clinic Orthopaedic Center at 3925 Embassy Parkway, Suite 250, Akron, OH 44333. Any agreed-to restriction will not limit patient directory disclosures unless you exclude yourself from the patient directory.
Complaints. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer, Director of Patient Access, or the Compliance Hotline. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. in writing within 180 days of a perceived violation of your rights. There will be no retaliation for ling a complaint.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer of Crystal Clinic Orthopaedic Center at 3925 Embassy Parkway, Suite 250, Akron, OH 44333, telephone (330) 670-6123. You may also call the Compliance Alert LJne of Crystal Clinic Orthopaedic Center at 330- 670-4799.
As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by email or other electronic means.
This Notice of Privacy Practices
is effective May 2009.
Revised March 26, 2013
I. CONSENT FOR MEDICAL PROCEDURES AND TREATMENT: Permission is hereby granted to the Crystal Clinic Orthopaedic Center, LLC (CCOC), Crystal Clinic Inc. (CCI), contracted providers, and all affiliated entities for such medical procedures, including the taking of photographs for diagnosis and treatment purposes only, as may be deemed necessary by my physician and/or his or her designee. Permission is also granted to CCOC, CCI, and affiliated entities for the taking of photographs, as reasonably necessary, for identification, health care operations and billing purposes. I consent to examinations, blood tests, laboratory and imaging procedures, medications, injections, infusions, nursing care and other services or treatments rendered by my physician, consulting physician, fellows, residents, interns, and their associates and assistants, or rendered by CCOC or CCI personnel under the instructions, orders or direction of such medical professional. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of treatments, examinations, emergency services, or hospital care.
II. CONSENT FOR BLOOD BORNE INFECTIOUS DISEASE TESTING: I hereby give my consent to have testing for blood-borne infectious disease, including, but not limited to Hepatitis, Acquired Immune Deficiency Syndrome (AIDS), and/or Human Immunodeficiency Virus (HIV) if a physician orders such test(s) or if ordered by protocol. The potential side effects of this testing are those encountered during the routine procedure of obtaining blood specimens. The results of this test will become a part of my confidential medical record. I understand that refusal to consent will not result in denial of admission and/or treatment by CCOC, CCI, or any of their affiliates. Notwithstanding the foregoing, I agree that if any healthcare worker is exposed to my blood or other bodily fluid, CCOC, CCI, or any of their affiliates may perform tests on my blood or other bodily fluid to determine the presence of any communicable disease. Any test result obtained as part of this process does not become part of my medical record.
III. CONSENT FOR CORONAVIRUS (COVID-19) TESTING:I hereby give my consent for CCOC to conduct collection and testing for COVID-19 as ordered by an authorized medical provider. The results of this test will become part of my confidential medical record. I understand my test results may be disclosed to the county, state, or to any other government entity as may be required by law. I understand the risk of contracting COVID-19 may result in the potential delay of my recovery.
IV. TEACHING PROGRAMS: I understand the CCOC is a facility that promotes teaching and education opportunities and, therefore, I may be seen and examined by supervised participants as part of the educational program.
V. PERSONAL VALUABLES: CCOC, CCI and/or any of their affiliates shall not be liable for loss or damage to any personal property of the patient including dentures, glasses, hearing aids, prostheses, money, jewelry, documents, other articles of unusual value and small size, etc. I understand and agree that if CCOC or CCI at any time believes there may be a weapon, explosive devices, illegal substance or drug, or any alcoholic beverage in my room or with my belongings, the hospital may confiscate any of the above items that are found and dispose of them as appropriate, including delivery of any items to law enforcement authorities.
VI. RELEASE OF INFORMATION: I authorize CCOC, CCI, and their affiliates, and any physician involved in my care, to use and disclose health information of the patient identified herein for purposes of treatment, payment, and health care operations, including but not limited to other persons or entities assisting CCOC, CCI, and their affiliates, in their treatment, payment and health care operations activities, including to employees and agents such as external legal counsel, any billing service, collections agency, or any other agents who may work on their behalf. I authorize any applicable employee or agent assisting the aforementioned entities in securing payment for services to contact me at any telephone number associated with my account(s), including wireless telephone numbers or other numbers provided in the past, present, or future, for the purposes mentioned above, including for securing payment for services or patient satisfaction surveys. I agree that methods of contact may include using an automatic telephone dialing system, text messaging, pre-recorded or artificial voice messages, and/or other computer-assisted technology. If my injury is work-related, I authorize the aforementioned entities to release any information from my medical record to my employer and/or its designee. This authorization specifically includes the release of medical information concerning drug-related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or infectious diseases including, but not limited to, blood borne diseases.
VII. FACILITY DIRECTORY: I understand that CCOC maintains a patient directory which includes patient name, room number, and general condition. I acknowledge that I must request to be excluded from the patient directory. By choosing to be excluded from the patient directory, my location in the hospital will not be released to any outside party.
VIII. OWNERSHIP INTEREST: I acknowledge that I have been given the CCOC Disclosure of Physician Ownership. I understand that the hospital is owned, in part, by physicians who may be providing my care, and that a list of those physicians can be provided for review upon request.
IX. TOBACCO USE POLICY: The Crystal Clinic Orthopaedic Center is a tobacco free facility. I understand that while I am a patient at the CCOC I may not use tobacco products and/or electronic cigarettes.
X. FINANCIAL AGREEMENT:In consideration of the services to be rendered to the patient, the undersigned individually promises to pay the patient’s account at the rates stated.
I understand that I am financially responsible to the CCOC, CCI, and their affiliates for charges not covered by my insurance company(ies), except as otherwise provided by Law. In the event that CCOC, CCI, and/or their affiliates has to engage an attorney or collection agency to collect any unpaid balances that arise from the treatment consented herein, the undersigned agrees to pay the reasonable attorney’s fees and collection expenses incurred by CCOC, CCI, and/or their affiliates.
An estimate of the anticipated charges for services to be provided to the patient is available upon request from CCOC, CCI and their affiliates. Estimates may vary significantly from the final charges based on a variety of factors, including but not limited to the course of treatment, intensity of necessity of providing additional goods and services.”
Patient Accounts’ Credit Balances. Patient hereby acknowledges that, in receiving care at the Crystal Clinic Orthopaedic Center (CCOC), he/she will be treated by CCOC medical staff personnel, many of which are employed by, or contracted with, Crystal Clinic, Inc. (CCI), an Ohio professional association. CCI physicians, CCI health care providers, CCOC physicians and CCOC health care providers may bill Patient independently for certain services performed at CCOC and CCI-affiliated facilities. Patient agrees that, if as a result of payment by Patient his/her account balance with either CCOC or CCI has a credit on one or more line item(s) or date(s) of service(s) and an unpaid balance for other services, whether such services were billed by CCOC or CCI, he/she expressly authorizes CCOC and CCI to apply the credit to the open line item(s) in order to settle, in whole or in part, any amounts due to CCOC or CCI by Patient.
XI. NOTICE: The majority of physicians, including anesthesia, radiology and pathology physicians, allied health practitioners and most surgeons that render professional services at CCOC are independent practitioners and are not employees or agents of the hospital. These providers are independent contractors acting as your (the patient’s) agent. CCOC is not responsible for the acts or omissions of the providers that are not directed or controlled by CCOC.
XII. ASSIGNMENT OF BENEFITS: I hereby assign to CCOC, CCI, their affiliates and CCOC’s physicians the right to be paid directly by my health insurance carrier or other health benefit plan for the services provided to me, my minor child, or other person entitled to health care benefits for the services provided in return for the services rendered and to be rendered by CCOC, CCI and/or facility-based physicians. I hereby authorize payment of these benefits otherwise payable to be my designated insurance company(ies), except as otherwise provided by law. This assignment and transfer shall be for the purpose of granting CCOC, CCI, their affiliates and/or physicians an independent right of recovery against my insurer or health benefit plan, but shall not be construed as an obligation of CCOC, CCI, their affiliates and/or physicians to pursue any such right of recovery.
XIII. MEDICARE PATIENT CERTIFICATION: I certify that the information given by me in applying for payment under Title XVIII and Title XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare / Medicaid claim. I permit a copy of the authorization to be used in place of the original and request payment of authorized benefits to be made on my behalf.
XIV. EMERGENCY TREATMENT:
Crystal Clinic Orthopaedic Center does not have a doctor of medicine or doctor of osteopathy present in the hospital 24 hours per day, 7 days per week. Therefore, a doctor of medicine or doctor of osteopathy may not be present during all hours services are furnished to you. CCOC is required by Federal Regulations (42 CFR 489.20 (w)) to inform you how care is provided in case of emergency when a physician is not on site. In such instances, the Crystal Clinic Orthopaedic Center facility will provide emergency treatment within capabilities of those medical personnel present and will summon emergency medical responders from the appropriate local jurisdiction.
During your stay in the Crystal Clinic Hospital, an Advanced Cardiac Life Support trained internal medicine provider (hospitalist) will be available to assist in your care 24 hours per day and 7 days per week. This provider may be a Nurse Practitioner or a Physician’s Assistant at times when an MD or DO is not physically present on site. The Nurse Practitioner or Physician’s Assistant will always have access to a physician who is on call if the need arises.
XV. PATIENT RIGHTS AND RESPONSIBILITIES ACKNOWLEDGEMENT: I certify that I have been provided a copy of the Patient Rights and Responsibilities and have had an opportunity to ask questions.
XVI. ACKNOWLEDGMENT OF ADVANCE DIRECTIVE I LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTHCARE: I have been offered Advanced Directive information and have been informed that additional information will be given to me at any time at my request during my hospitalization, outpatient, or other visit.
Do you have a Living Will? Yes or No.
Durable Power of Attorney for Healthcare? Yes or No.
I acknowledge that my Living Will, according to CCOC and CCI policy, will not be implemented during any visit to a satellite facility (e.g., outpatient surgery center, hospital based physician clinic) for outpatient services, while in surgery, or during the immediate post-operative period.
XVII. NOTICE OF PRIVACY PRACTICES: I acknowledge that I have been provided a copy of the CCOC, CCI and their affiliates Notice of Privacy Practices. I understand that if I have questions or complaints, I may contact the CCOC’s HIPAA Privacy Officer.
XVIII. STATEMENT OF NONDISCRIMINATION: Crystal Clinic Orthopaedic Center and Crystal Clinic, Inc. comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-481-3289.
注意：如果您使用繁體中文，您可以免費獲得 語言援助服務。請致電 1-800-481-3289.
I hereby certify and state that I have read, and that I fully and completely understand the above Conditions of Admission and Authorization for Medical Treatment, and that I have signed this Conditions of Admission and Authorization for Medical Treatment knowingly, freely, and voluntarily.
DISCRIMINATION IS AGAINST THE LAW
Crystal Clinic Orthopaedic Center and Crystal Clinic, Inc. (Crystal Clinic) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Crystal Clinic does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Crystal Clinic provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Crystal Clinic provides free language services to people whose primary language is not English, such as Qualified interpreters and Information written in other languages.
Mailing Address: 3925 Embassy Parkway Suite 250H Akron, OH 44333
Telephone number: (330) 670-4078
Fax: (330) 668-2875
If you believe that Crystal Clinic has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Crystal Clinic’s Patient Experience Office. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Crystal Clinic’s Patient Experience Office is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
|ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1- 800-481-3289.
|XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-481-3289.
|注意：如果您使用繁體中文，您可以免費獲得 語言援助服務。請致電 1-800-481-3289.
|주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-481- 3289.
|ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-481-3289.
|ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-481-3289.
|ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. -اتصل برقم 1-800-481-3289
|注意事項：日本語を話される場合、無料の言語支 援をご利用いただけます。 1-800-481-3289.
|Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-481-3289.
|AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 1- 800-481-3289.
|ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-481-3289.
|УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером м 1- 800-481-3289.
|ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-481-3289.
|ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-481-3289.
|CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-481- 3289
ACKNOWLEDGEMENT OF FACILITY CHARGES ASSOCIATED WITH COMMON MINOR SURGERY/INJECTION SERVICES
|AVERAGE COMMERCIAL REIMBURSEMENT
|CCOC CHARGE AMOUNT
|Injection, therapeutic, carpal tunnel
|Bilateral injection, therapeutic, carpal tunnel
|Injection(s); single tendon sheath, or ligament, aponeurosis
|Injection(s); single tendon origin/insertion
|Trigger Injection 1-2 Muscles
|Arthrocentesis, aspiration and/or injection; small joint or bursa
|Bilateral arthrocentesis, aspiration and/or injection; small joint or bursa
|Arthrocentesis, aspiration and/or injection; intermediate joint or bursa
|Bilateral arthrocentesis, aspiration and/or injection; intermediate joint or bursa
|Arthrocentesis, aspiration and/or injection; major joint or bursa
|Bilateral arthrocentesis, aspiration and/or injection; major joint or bursa
|Aspiration and/or injection of ganglion cyst(s) any location
|Celestone (betamethasone per 3mg)
|M-Pred 40mg, 5ml
|Kenalog per 10 mg
|Durolane 60 units
|Orthovisc (hyaluronan 15mg/ml)
|Synvisc (per 16 mg)
|Synvisc One (per 48 mg)
|Gel One 30mg/3ml
Have questions? Call our Billing Office at (800)818-0886
The procedure code(s) above represent the surgical/injection services that may be recommended by my provider. The above procedure(s) is (are) not the only services for which I will be charged during this visit. Other fees will include separate charges for provider professional services and, if provided, medications, x-ray, lab, pathology, durable medical equipment, physical or occupational therapy services, etc.
If the charges for services provided are covered by insurance and the CCOC is contracted with your payer, you will only be billed for the amount deemed appropriate by your payer (e.g. co-insurance, patient responsibility and deductible amounts).If you have no insurance, you will receive at least a 55% discount (80% on injection charge only) on the charges above based on an evaluation with a CCOC Financial Counselor.
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