1. We commit to treating you with consideration and respect, in full recognition of your dignity and individuality.
2. You have the right to receive care in a safe setting.
3. We commit to respecting your privacy in treatment and personal care. The right to personal privacy includes physical privacy to the extent consistent with your care needs during personal hygiene activities (e.g., toileting, bathing, or dressing), during medical/nursing treatments, and when requested (as appropriate).
4. Except as permitted by New Hampshire law, you have the right to be informed of the name, licensure status, and staff position of all hospital staff and personnel that you have contact with.
5. You have a right to be fully informed of your rights and responsibilities as a patient. You have a right to be fully informed of all procedures governing patient conduct and responsibilities. We will provide this information orally and in writing before or at admission (except during emergencies). As a patient, it is your responsibility to acknowledge receipt of this information in writing. (When a patient lacks the capacity to make informed judgments, the signing must be done by the person legally responsible for the patient).
6. You have a right to be fully informed in writing (in language that you can understand), before or at the time of admission—and as necessary during your stay—of our basic per diem rate. You have a right to be informed of those services included and not included in the basic per diem rate. A statement of services that are not normally covered by Medicare or Medicaid shall also be included in this disclosure.
7. You have the right to make informed decisions regarding your care. Except where it is medically inadvisable, we commit to informing you fully of your medical condition, health care needs, and diagnostic test results, including the manner by which such results will be provided and the expected time interval between testing and receiving results.
8. You shall be given the opportunity to participate in the development and implementation of your plan of care. This includes participating in the development and implementation of inpatient care plans, outpatient care plans, discharge plans, and pain management plans (as applicable). You shall be given the opportunity to refuse treatment.
9. You will not be involved in experimental research without your written consent.
10. You will be transferred or discharged only in accordance with applicable law.
11. You will never be discharged involuntarily from our facility solely because you have become eligible for Medicaid as a source of payment.
12. We commit to encouraging and assisting you, throughout your stay, in exercising your rights as a patient and citizen.
13. You have the right to voice grievances and to recommend changes in policies and services to facility staff or outside representatives free from restraint, interference, coercion, discrimination, or reprisal. Notify your physician, nurse or the North Country Healthcare (NCH) Compliance Officer, 8 Clover Lane, Whitefield, NH 03598, Telephone: (603) 326-5608, or Email, email@example.com. You may also contact the NH Department of Health and Human Services Health Facility Certification Unit, 129 Pleasant Street Concord, NH 03301-3857, Telephone: (603) 271-9049 or 1-800-852-9049, Email, DHHS.HFA-Certification@dhhs.nh.gov or the HHS Office for Civil Rights Complaint Portal, which is available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsj, or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-567-7697 (TDD).
14. You have the right to manage your personal financial affairs.
15. You have the right to be free from emotional, psychological, sexual, and physical abuse. You have the right to be free from exploitation, neglect, corporal punishment, and involuntary seclusion.
16. You have the right to be free from chemical and physical restraints except when they are authorized in writing by a physician for a specific and limited time necessary to protect you or others from injury. In an emergency, other designated professional staff members may be authorized to protect you or others from injury. Restraints and seclusion will never be imposed as a means of coercion, discipline, convenience, or retaliation by staff.
17. We commit to the confidential treatment of all information contained in your personal and clinical record, including that stored in an automatic data bank. Your consent shall be required for the release of information to anyone not otherwise authorized by law to receive it.
18. Medical information contained in our medical records is deemed to be your property. You are entitled to a copy of such records upon request. The charge for the copying of your medical records shall not exceed $15 for the first 30 pages or $.50 per page, whichever is greater; provided, that copies of filmed records such as radiograms, x- rays, and sonograms shall be copied at a reasonable cost.
19. We will never require patients to perform services for our facility. Such services will only be included in a plan of care and treatment if you agree to them and if they are appropriate for therapeutic or diversional purposes.
20. You are free to communicate with, associate with, and meet privately with anyone, including family and resident groups, unless to do so would infringe upon the rights of other patients.
21. You have the right to send and receive unopened personal mail.
22. You have the right to have regular access to the unmonitored use of a telephone.
23. You have the right to participate in activities of any social, religious, and community groups, unless to do so would infringe upon the rights of other patients.
24. You have the right to retain and use personal clothing and possessions as space permits, provided it does not infringe on the rights of other patients. Note that we are in no way responsible for the security of your personal belongings. We recommend that you keep valuable objects at home. Some of our facilities may contain a safe. More information is available upon request.
25. You are entitled to privacy for visits and, if married, to share a room with your spouse (so long as you are both in the same facility and so long as both patients consent), unless it is medically contraindicated.
26. You have the right to reside and receive services in the facility with reasonable accommodation of your needs and preferences, including choice of room and roommate, except when your health and safety (or the health and safety of other patients) would be endangered.
27. You shall not be denied appropriate or otherwise be discriminated against care on the basis of age, sex, gender identity, sexual orientation, race, color, marital status, familial status, disability, religion, national origin, source of income, source of payment, or profession.
28. You are entitled to be treated by your physician of choice, subject to our rules and regulations and our credentialing process. Be advised that some facilities utilize predetermined rosters of “on-call” practitioners to coordinate patient care.
29. If you are admitted to one of our hospital facilities, you have the right to have a family member or representative of your choice notified promptly of your admission. In addition, you have the right to have your own physician notified of your admission.
30. You may receive visitors in accordance with facility policy. You may withdraw or deny consent to receive visitors at any time.
31. If you are a minor, you are entitled to have your parents visit the facility, without restriction, if you are considered terminally ill by the physician responsible for your care.
32. You are entitled to have your spouse, unmarried partner, or next of kin, or a personal representative chosen by you visit the facility, without restriction, if you are considered terminally ill by the physician responsible for your care.
33. You are entitled to receive representatives of approved organizations in accordance with New Hampshire law.
34. When there is an available space in our facility, you shall not be denied admission to the facility based on Medicaid as a source of payment.
35. Subject to the terms and conditions of your insurance plan, you shall have access to any provider in your insurance network. Referral to a provider or facility within this network will not be unreasonably withheld.
36. You have the right to formulate Advance Directives (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decisionmaker. We commit to honoring that directive to the extent permitted by law and facility policy. When presented with an Advance Directive, we will provide you with information about our facility policies on Advance Directives. If you have questions about your right to formulate an Advance Directive, please ask and we will provide you with more information.
37. NCH and its affiliates will provide free aids and services to people with disabilities to communicate effectively with us, such as: (i) qualified sign language interpreters; and (ii) written information in other formats (large print, audio, accessible electronic formats, other formats). They will also provide free language services to people whose primary language is not English, such as: (i) qualified interpreters; and (ii) information written in other languages.
1. You have the responsibility to be considerate of the rights of other patients and of all other individuals you meet in our facility.
2. You have the responsibility to be respectful of our property and of the property of other persons.
3. You have the responsibility to provide your health care team with accurate and complete information about your health status, to the best of your knowledge. This includes information about present complaints, past illnesses, prior hospitalizations, medication usage, and other matters relating to your health.
4. If there is an unexpected change in your condition, you have the responsibility to report that to the practitioner responsible for your care.
5. You have the responsibility to request information about anything that you do not understand.
6. You have the responsibility for following your treatment plan. This may include following the instructions of nurses and other members of the health care team. You are responsible for the consequences of refusing treatment or failing to follow your health care practitioner’s instructions.
7. You have the responsibility to keep appointments. If you cannot keep an appointment, you have the responsibility to notify our facility as soon as possible.
8. You have responsibility for all financial obligations of your care. This includes providing information about your insurance and working with the facility to arrange payment. Financial obligations should be fulfilled as soon as possible.
9. As a patient, you must never bring weapons into our facility.
10. You have the responsibility to comply with all facility policies governing patient conduct.
11. Your health depends not just on the treatment you receive, but also on the decisions you make in your everyday life. You are responsible for recognizing the effect of lifestyle upon your personal health.
Dated: April 2021