WELCOME TO THE CRYSTAL CLINIC ORTHOPAEDIC CENTER

YOUR RIGHTS

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.

CARE DELIVERY

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.

VISITATION

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.

COMMUNICATION

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.

HOSPITAL BILLS

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 or writing:
  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 complaint@jointcommission.org
• Medicare Beneficiaries Only:
  LIVANTA, LLC
  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.

YOUR RESPONSIBILITIES

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.

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.

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.”