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Important Registration and Billing Information. Schneider Regional Medical Center 9048 Sugar Estate St. Thomas, VI 00802 www.srmedicalcenter.org. Welcome to Schneider Regional Medical Center Patient Financial Services.

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Important Registration and Billing Information

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Important registration and billing information

Important Registration and BillingInformation

Schneider Regional Medical Center

9048 Sugar Estate

St. Thomas, VI 00802

www.srmedicalcenter.org


Welcome to schneider regional medical center patient financial services

Welcome to Schneider Regional Medical Center Patient Financial Services

  • A hospital visit can often be a confusing time. Knowing what to expect can really put your mind at ease. That’s why we’ve made it one of our top priorities to keep you informed about our processes, including our billing procedures.

  • We understand that a Hospital Stay or Outpatient testing can be a time of concern and anxiety for you and your family. Please take this opportunity to review some of the processes that you may encounter.

  • You may be asked to sign in at the reception desk. Due to clinical necessity there may be times when patients are registered out of order. We will assist you with the same urgency as soon as possible.

  • You are responsible for your own valuables and personal items while you are in the hospital. Therefore we ask that other than sufficient funds to meet your co-payment/deposit requirements, you leave your valuables at home.

  • We will collect and file your insurance for you. Following your visit or stay you will receive monthly bills telling you the status of your claim. These bills will show what has been billed to insurance and will not have a patient balance due on them. We encourage payment of co-insurance and deductibles up front or you may pay them at any time following your time here.


Important registration and billing information

  • Insurance:

  • Your co-pay, deductible and/or co-insurance are due at the time of service. Payments can be made by cash, debit cards, personal check, travelers check, EFT (Electronic Funds Transfer) or by credit card (Visa, MasterCard and American Express).

    • If we do not have the exact amount due at time of service, we will require a deposit. The deposit may vary, depending on the particular type of service.

    • Medicare patients should be prepared to pay their inpatient deductible at the time of admission.

    • “Medicare patients, we are required by Medicare to check the diagnosis information that your ordering physician has provided with the specific test or procedure he/she has ordered when you are scheduled for Outpatient services. In some cases, Medicare will not pay for a service because they feel that the diagnosis does not support the need for the test or service requested by your physician.”

    • Please have your insurance card (s) and proof of identification readily available.


Important registration and billing information

  • Self-Pay:Patients with no insurance agree to pay estimated charges prior to treatment. Because we realize that health care is expensive, self-pay patients are given an automatic 40% discount at the time of billing. To obtain the estimated cost of your service, please contact Patient Financial Service. Any additional charges incurred during the visit are the patients’ responsibility. If you are a Self-Pay patient, all payments are expected at the time of registration. If you are unable to pay, we will require a substantial deposit towards your care. The amount of that deposit will be directly proportional to the class of service you are scheduled to receive.

    • Financial Assistance Programs (Federal, State and Local) are available). Patients or immediate family members should contact a Financial Counselor for assistance.

  • Pre-Certification:Your insurance coverage is a contract between you and your insurance company. Benefits will vary depending upon the type of insurance policy you carry.

    • If your insurance requires pre-certification or an authorization, we will attempt to obtain them for you before your service (s), however, remember it is your responsibility to notify your insurance company of services that require pre-authorization or pre-certification.

    • If we have not been able to obtain authorization, we may need to cancel or reschedule your service (s).

  • Pre-Registration:We can pre-register any visit arranged in advance by a physician. Through advance registration, all of the required information about you is gathered and placed in our files pending your visit. Your service representative will discuss financial requirements with you at that time.

  • If your Physician schedules your service in advance, we will attempt to contact you to update your demographic information before you arrive.

  • Your co-payment, deductible and co-insurance are due at the time we are pre-registering you. Payment may be made by cash, check, or credit card.

  • If you would like to schedule any service (s) in the future and would like to contact us to pre-register, please call 340-776-8311 and request Registration Services. Contact us at least (3) days prior to your service.

  • Registration:We offer services without regard to religion, race, sex, age, national origin, or handicap. Your Service Representative will help you complete the appropriate paperwork required for your hospital visit.

  • Registration will consist of the following:

    • A Confirmation of your demographic information

    • Verification that pre-certification has been obtained

    • Collection of payments that are due

    • Order for the test (s) requested by your Physician.


Important registration and billing information

  • Hospital Billing Guide:We are providing this guide to inform you of what you can expect regarding hospital charges for services provided to you today, if you have insurance.

  • Your hospitalization coverage is a contract between you and your commercial insurance company. You are responsible for your hospital account.

  • We will bill your insurance on your behalf as a courtesy. Your coverage is a contract between you and your insurance company. During the process of filing your claim, you will receive a variety of letters to keep you informed of the status of your account.

  • Please be advised that you may obtain informational statements until your insurance company correctly pays your claim. You may want to call your insurance company to see what is causing the delay. In many instances, the insurance company is waiting for information from you or the subscriber.

  • After receiving the insurance payment, you will receive an Explanation of Benefits from your insurance company telling you how the claim was processed and informing you of your financial responsibility (co-pays, deductibles, and/or co-insurance).

  • At the time the bill is sent you your insurance company, you will receive an itemized statement from the hospital which will reflects your hospital care, and all the supplies and services ordered by your physician. If you need an insurance billing form for billing other insurance, we can provide you with a copy if you contact Patient Financial Services. However, your Hospital Bill must first be paid in full.

  • Physician Billing:You should expect to receive a separate bill from the Physician’s that may assist in caring for you.

  • During the course of your stay, your physician may request consultations and/or services of hospital-based physicians including but not limited to, emergency physicians, radiologists, pathologists, and anesthesiologists.

  • The physicians associated with this hospital may be independent, private practicing physicians, and may be individually contracted with an insurance company. Contact your insurance company to verify that both the Hospital and the Physician are contracted with your Insurance Provider Network. You should expect to receive a separate bill from your Physician (s) listed below, if applicable:

    • Emergency Physicians: Will be billed via our billing system for any services you may have received while in the Emergency Department.

    • Radiologists: Will bill you for reading any X-rays that were taken while at the hospital.

    • Pathologists: Will bill you for any laboratory and pathology test (s) they have read while you were at the hospital.

    • Anesthesiologists: will bill you for services received during any surgical procedures you may have undergone while at the hospital.


Consent for admission to hospital medical treatment release of records and responsibility

Consent for Admission to Hospital, Medical Treatment, Release of Records and Responsibility

Name:_____________________________________________Date:___________________ Time:_____________________

1.I/We the undersigned, knowing that _________ is suffering from a condition requiring diagnosis and medical or surgical treatment hereby voluntarily consent to such diagnostic procedures and hospital care by or under the supervision of Dr. ______.

  • I/We are aware that the practice of medicine or surgery is not an exact science and I/We acknowledge that no guarantees or assurances have been made to me/us with regard to the results that may be obtained from treatments or examinations in the hospital.

  • I/We acknowledge that the Schneider Regional Medical Center does not assume responsibility for loss or damage to personal property kept in the patient’s room. I/We further acknowledge that while the safe is available for the keeping of money and valuables of the patient, the Schneider Regional Medical Center assumes no responsibility for any possessions deposited therein.

  • I/We consent to allow students from formal education programs for health care professions to participate in my/the patient’s care, under the supervision of appropriately licensed an/or credentialed members of such disciplines.

  • I/We acknowledge that I/We have received a written document regarding my/the patient’s rights under Virgin Islands law to make decisions about my/the patient’s medical care, and specifically about advance directives, (i.e. living wills, etc.) NOTE: Included in this document is information about the Schneider Regional Medical Center’s policies as regards advance directives.

  • I/We consent to the release of information to friends, relatives and others who may inquire, information to be released includes: patient’s name, admission or discharge, medical condition in general terms, hospital room and hospital phone number.

  • If applicable, I/We authorize the Schneider Regional Medical Center’s pathologist to use his discretion in the disposal of any specimen or tissue obtained from the patient during the course of diagnosis or treatment.

  • If applicable, I/We consent to the administration of such anesthetics as are necessary and applied by or under the direction of the medical anesthesia department. Note exceptions, if any____________________.

  • I/We understand that some insurance companies require authorization for inpatient admissions or specific procedures, and that maximum reimbursement may not be received if authorization is required and I/We do not have it, I/We assume the responsibility of obtaining such authorization if necessary and understand that Schneider Regional Medical Center cannot obtain such authorization for me/us.

  • I/We authorize Schneider Regional Medical Center and/or any doctor involved with my/the patient’s care including those performing diagnostic radiology (x-ray) services, anesthesiology services, pathology services, emergency services, or other similar specialty services to release any information from my/the patient’s medical record as requested by the patient’s insurance company for payment of the hospital’s or physician’s accounts.

  • I/We assign all insurance benefits due to or received by me/us to Schneider Regional Medical Center, and/or the doctors involved with my/the patient’s care including those performing Radiology, Anesthesiology, Pathology or Emergency Services; or other similar specialty services as total or partial payment for services provided. I/We understand that this assignment may not constitute full payment of my/the patient’s bill, and does not relieve me/us from liability for the unpaid balance. If insurance benefits to which I/the patient (s) are entitled are paid directly to me/us, such benefits will upon be immediately delivered to Schneider Regional Medical Center (or the appropriate physician) by me/us until the full amount of all charges incurred are paid in full.

  • I/We agree to pay directly to Schneider Regional Medical Center and/or such doctors the charges incurred for services rendered/received, at their established rates. I/We will pay all attorney’s fees and court costs incurred by Schneider Regional Medical Center or such doctors in collecting any unpaid balances for services I/the patient received.

    DO NOT SIGN THIS FORM UNTIL YOU HAVE READ IT AND UNDERSTAND ITS CONTENTS

    _____________________________________________________________________________

    (WITNESS)(SIGNATURE OF PATIENT)

    (IF PATIENT IS UNABLE TO CONSENT OR IS A MINOR, COMPLETE THE FOLLOWING:)

    Patient is a minor _____ years of age (or is unable to consent because: _______________________________________)

    ____________________________________________________________________________

    (WITNESS)(SIGNATURE OF CLOSEST RELATIVE OR LEGAL GUARDIAN)

    CONSENT FOR DELIVERY AND CARE OF NEWBORN

    If applicable, I/We authorize the delivery, care, and treatment of both mother and newborn infant as explained by the designated physician (s).

    I/We consent to the performance of any other procedures as are considered necessary by said physician on the basis of findings during the course

    Of care and treatment of mother and/or infant. I/We specifically understand that I/We are consenting not only to my/the mother’s care, but the care of the newborn as well.

    _____________________________________________________________________________

    (WITNESS)(SIGNATURE OF PATIENT)

    (If patient is an un-emancipated minor, complete the following – in addition to the patient’s signature above: )

    Patient is a minor _____ years of age (Or is unable to consent because: _________________________________________________ )

    ____________________________________________________________________________

    (WITNESS)(SIGNATURE OF CLOSEST RELATIVE OR LEGAL GUARDIAN)


Medicare information for our patients

Medicare Information for our Patients:

  • Medicare fraud steals millions of dollars every year from the Medicare program. Beneficiaries pay for it with higher premiums. Fraud occurs when someone knowingly deceives or misrepresents themselves in a way that could result in unauthorized payments being made. Fraud schemes may be carried out by individuals, institutions, or groups of individuals.

  • Medicare fraud includes, but is not limited to:

    • Billing for more expensive services at a higher service fee than was actually provided.

    • Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment.

    • Billing for services not furnished.

    • Soliciting, offering, or receiving a kickback.

    • Billing separately for services that should be included in a single service fee.

    • Misrepresenting the diagnosis to justify payment.

  • Medicare is improving its capability to crack down on those who take advantage of this program. We are using four methods to fight fraud and abuse: prevention, early detection, coordination with other government agencies, and prosecution of wrongdoers.

  • We need your help to stop Medicare fraud and abuse. You can help protect Medicare and yourself by reporting all suspected instances of fraud and abuse. When you receive payment notices from Medicare, review them for errors. Make sure Medicare did not pay for services, medical supplies, and/or equipment that you did not receive.

  • Reporting Medicare Fraud and Abuse:

  • If you have a questionable charge on your bill, call the provider, your Fiscal Intermediary (for Part A bills) or your Medicare carrier (for Part B bills). If you believe that a health care provider may be cheating or abusing the Medicare program, call the Medicare carrier or intermediary that sent you the payment notice. Their name, address, and telephone number appear on the payment notice. After you call the Medicare carrier or Fiscal Intermediary, you may also call the Inspector General’s hotline at 1-800-HHS-TIPS (1-800-447-8477), or TTY for hearing and speech impaired: 1-800-377-4950.

  • From publication No. HCFA 10111


Important registration and billing information

Patient’s Rights and Responsibilities

Patient Advocacy Information

Copy received Patient or Legal Guardian:_________________________Date:______________

Admitted by: ________________________________________________Date:______________

To Our Patients:In accordance with the Admissions/Registration Policies and Procedures of the Schneider Regional Medical Center, it is our obligation to inform you and your family members of the following policies involving:


Important registration and billing information

Patient Rights & Responsibilities

The Schneider Regional Medical Center DBA Roy Lester Schneider Hospital, Myrah Keating Smith Community Health Center and Charlotte Kimmelman Cancer Institute are dedicated to serving the whole patient regardless of race, creed, social or economic status, believing that the rights and dignity of every patient must be protected and promoted with care. The hospital and health center endeavor to protect the patient’s rights to privacy and keep patient records and communications confidential, in accordance with professional ethics and the law. The Schneider Regional Medical Center organizations are committed to safeguarding the right of each patient to information about and participation in decisions regarding medical care, and to promoting respect and dignity for all individuals. In the case of a minor, the following rights and responsibilities are afforded the patient’s parent or guardian.

  • You Have the Right To:

  • Considerate and respectful care, which optimizes your comfort and dignity throughout your treatment.

  • Access to treatment regardless of gender, age, disability, ethnicity, religion, or source of payment. This includes the right to supportive social and pastoral services that respect your personal value and belief system.

  • Expect that every attempt will be made to provide an interpreter, if your spoken language is not English, or if you are deaf or hearing impaired.

  • Receive aggressive, timely and appropriate pain management when indicated.

  • Participate in the consideration of ethical issues that arise in the course of your care.

  • Personal privacy and confidentiality. Be free from all forms of abuse or harassment, including the right to access protective services, if needed.

  • Receive information about, and an explanation of, your hospital bill.

  • Request a copy of your completed medical record and obtain the copy within a reasonable timeframe.

  • To know if this hospital/health center has relationships with outside parties that may influence your treatment and care. These relationships may be with educational institutions, other health care providers, or insurers.

  • Be treated by skilled, compassionate, caring physicians, nurses, and hospital staff.

  • Know the names and roles of the providers caring for you.

  • Be well informed about your illness, possible treatments, likely and unanticipated outcomes, and to discuss this information with your healthcare provider.

  • Be advised if the hospital/health center proposes to engage in research projects affecting your care or treatment, and the right to refuse to participate in such studies without compromising the quality of care you receive.

  • Receive a high standard of patient care and safety while in the hospital setting. The hospital/health center, your doctor, and health care professionals will protect your safety and security as much as possible.

  • Be free from chemical or physical restraint except as authorized by a physician or in an emergency when necessary to protect you or others from injury.

  • Receive appropriate discharge teaching and instruction for self-care, including awareness of community resources available to provide supportive care.

  • Act in partnership with your health care providers to make decisions regarding your care.

  • “Advance Directives”: you have the right to formulate an Advance Directive or to appoint a surrogate to make health care decisions on your behalf.

  • Informed consent, including the right to have treatment options explained so that you understand the benefits, risks, and treatment choices.

  • Refuse treatment to the extent permitted by ethics and law, and to be informed of the medical consequences of your action.

  • To obtain pertinent information information as to any relationship of this hospital/health center and other health care institutions which may affect your care.

  • It Is Your Responsibility To:

  • Be Part of Your Care

  • Be as accurate and complete as possible when providing medical history and treatment information.

  • Inform your health care provider if you have any questions regarding care and treatment.

  • Partner with the health care providers to develop an appropriate plan of care.

  • Participate in the designated plan of care.

  • Notify your health care providers if the designated plan of care cannot be followed.

  • Provide a copy of your “Advance Directive" to the hospital/health center.

  • Notify your health care providers or the Patient Representative at x2302/Administrator MKSCHC 693-8900 if you are not satisfied with the care you received.

  • Respect and Consider the Rights of Others

  • Be considerate of the rights of other patients and their families.

  • Be considerate of the physicians and hospital/health center personnel.

  • Provide the hospital/health center with accurate and timely information concerning the sources of payment and ability to meet financial obligations associated with care.

  • Ensuring a Safe Hospital Stay

  • The single most important way you, as a patient, can help to prevent errors is to be an active member of your health care team. Speak up! if you have any questions or concerns.

  • Discuss your concerns with your nurse, physician, or if you have a commendation or complaint about the quality of your care, you may call the Hospital Operator to page the Patient Representative or after hours, page the Nursing Supervisor. At Myrah Keating, Contact the Administrator.


Patient relations

Patient Relations

  • The Patient Relations Department at Schneider Regional Medical Center is here to serve as the Patient’s Advocate. Our mission is to address questions or concerns you or your family members may have about care, hospital policies and procedures, or the quality of hospital services. Patient Relations representatives are also happy to receive compliments, suggestions, and other recommendations that might improve the services provided by this facility.

  • Compliments: if you would like to thank a special staff member or volunteer who made your hospital stay especially comfortable, Patient Relations can assist you. Our team members are energized by receiving suggestions or recommendations for future improvements. A word of thanks from the patients we care for helps to lift our spirits and morale! We encourage you to send cards, emails, or any other correspondence about the service you may have received.

  • Grievances and Concerns: If you have a complaint, you may register it verbally or in writing with a representative. Your particular concern will be investigated and a resolution will be provided as soon as possible.

  • As a Medicare patient, you also have the right to have your grievance regarding quality of care or premature discharge referred to and independently reviewed by the Virgin Islands Medical Institute Peer Review Organization (VIMI PRO). If you would prefer to contact the VIMI PRO directly, you may do so at 340.712.2400 or 712.2449. An independent review of your case will be conducted. This procedure can be initiated at your request, via Patient Relations and the Office of the Medical Director.

  • If you have a complaint regarding a HIPAA privacy violation, you may direct it to The Director of Privacy, Compliance and Health Information Management, Ms. Patricia Lake-Blyden, RHIA at:

    • Extension 2253

    • 9048 Sugar Estate

    • St. Thomas, VI 00802

  • In the even that you or your family would like to file your grievance outside of the Hospital’s internal grievance process, you may forward your written grievance to:

    • Commissioner of Health, or Designee

    • USVI Department of Health

    • 9048 Sugar Estate, 5th Floor

    • St. Thomas, VI 00802

    • 340.774.0117

  • When sharing your compliments and concerns with our department, please be sure to include your name, date of stay, the unit, the nature of the issue, the names of any individuals whom you feel are important to the issue at hand, and how you would like to see the matter resolved.

  • Our hospital also conducts Patient Satisfaction Surveys through a nationally recognized survey research consultant firm: The Jackson Organization. After you have completed your service and have been discharged, you may receive a call from the surveyors. Please feel free to share your responses with them. They compile the important information that you share with them, and submit it to our Hospital’s Administration so that we can continue to improve our services and processes.

  • Patient Relations Contact Information:

    • Christine deJongh-Lewis, MPH

    • Hours: Monday through Friday, 8 AM to 5 PM

    • Location: Schneider Regional Medical Center Administration

    • Mailing Address: 9048, Sugar Estate, St. Thomas, VI 00802

    • Telephone: 340.776.8311 x 2302, 2201

    • E-Mail: [email protected]

  • After hours and on weekends, in non-urgent situations, please leave a message. If you have an emergency, please contact the Nursing Supervisor or Administrator on Duty.

  • Rev 11/04


Medicare appeals and grievances complaints

In the Original Medicare Plan: If you are dissatisfied, you have a right to appeal any decision concerning your Medicare covered services in the Original Medicare Plan. You can file an appeal if you believe Medicare did not pay enough for services or should have paid for health care services you received. Your appeal rights will be detailed on the back of the Medicare Summary Notice (MSN) or Explanation of Medicare Benefits (EOMB) that is mailed to you.

If you believe you are being discharged too soon from a hospital, you have a right to immediate review by the Peer Review Organization. Peer Review Organizations (PROs) are groups of practicing doctors and other health care professionals paid by the federal government to monitor the care given to Medicare patients. They are responsible for reviewing beneficiary complaints about the quality of care provided by inpatient hospitals, hospital outpatient departments and hospital emergency rooms; skilled nursing facilities; home health agencies; Medicare Managed Care Plans and ambulatory surgical centers. You can stay in the hospital at no charge and cannot be discharged before the PRO makes a decision.

In Other Medicare Health Plans: You have a right to appeal decisions concerning your Medicare benefits in the other Medicare health plans. If you have any concerns or problems with your plan, you also have a right to file a grievance (complaint). You have these rights regardless of the type of plan in which you are enrolled. To participate in Medicare, each health plan must have an appeal and grievance process for its members. See the health plan’s membership materials or contact your health plan for details about your rights and how to file a Medicare appeal and complaint.

You may file an appeal if your health plan denies a service or terminates or refuses to pay for services that you believe should be covered. You may be eligible for a fast decision (within 72 hours) if you believe that your health or ability to function could be seriously harmed by waiting the amount of time needed for a standard decision. Your health plan must provide you with written instructions on how to appeal. The first step is to contact your plan.

After you file an appeal, the health pan reviews its original decision to deny you coverage. Then if your health plan does not decide in your favor, the appeal automatically goes to an independent reviewer that contracts with Medicare.

If you believe you are being discharged too soon from a hospital, you have a right to immediate review by the Peer Review Organization (PRO) in your State. During the immediate PRO review, you may be able to stay in the hospital at no charge and the hospital cannot discharge you before the PRO reaches a decision.

From publication No. HCFA 10119

Medicare Appeals and Grievances (Complaints)


Hipaa notice of privacy practices

HIPAA Notice of Privacy Practices

  • Your Privacy Rights:

    • The following is a summary of your rights with respect to your protected health information: (Please be aware that the Schneider Regional Medical Center can deny your requests in certain circumstances.)

      • You may request a restriction on uses and disclosures of your health information.

      • You may request that our communications to you be confidential.

      • You may request to inspect and copy your protected health information ( we may charge a fee for copying your record.)

      • You may request an accounting of disclosures of your health information.

      • You may request an amendment of your protected health information.

      • You have the right to receive a copy of the complete Notice of Privacy Practices.

  • You should also know that if you have greater protections under a specific U.S. Virgin Island statute or regulations, those protections will continue to apply to you.

  • Complaints or Additional Information

    • You may file a complaint to us or to the Secretary of Health and Human Services if you believe that we have violated your privacy rights. You may also request additional information about this Notice of Privacy Practices.

  • Write to:

    Roy Lester Schneider Hospital

    Attention: Patricia Lake-Blyden, Compliance and Privacy Officer

    9048 Sugar Estate

    St. Thomas, VI 00802

  • Other Complaint Filing Information:

    USVI Department of Health

    Commissioner of Health

    9048 Sugar Estate, 5th Floor

    St. Thomas, U.S.V.I. 00802

  • PRO Complaint Filing Information:

    Peer Review Organization

    #1AD Estate Diamond Ruby

    PO Box 5989, Sunny Isle

    St. Croix, VI 00823

  • Effective Date: April 14, 2003

  • 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.

  • This is a summary notice of your rights. The complete Notice of Privacy Practices is available at the Registration or Admissions Office.


Hipaa notice of privacy practices hospital health center responsibilities

HIPAA Notice of Privacy PracticesHospital/Health Center Responsibilities

  • Schneider Regional Medical Center is required by law to maintain the privacy of your protected health information and to give you notice of our duties and privacy practices. This Notice describes how we may use and disclose your individually identifiable health information. This Notice also describes your rights to access and control your health information.

  • We must follow the terms of this Notice. We reserve the right to change this Notice consistent with the law. If we change this Notice, we will post a revised Notice and will make paper copies of the complete Notice available upon request. The terms of this Notice of Privacy Practices are consistent with the federal “HIPAA Privacy Regulations”. Any term not defined in this Notice have the same meaning as it has in the HIPAA Privacy Regulations.

  • Uses and Disclosures of Your Protected Health Information:

    • We are legally permitted, without further notice to or consent from you, to use and / or disclose your protected health information in the following circumstances.

      • For treatment, payment or healthcare operations or to others involved in your care

      • To other covered entities or for public health activities

      • To the Food and Drug Administration (FDA)

      • For Workers’ Compensation or in other legal proceedings

      • To Coroners, Medical Examiners, Funeral Directors, Organ Donation Agencies

      • For approved research

      • For disaster relief programs or health oversight activities

      • To business associates

      • For abuse or neglect reporting or as otherwise required by law

      • Health-related benefit information

      • To law enforcement personnel or for inmates of prison facilities

      • Military activity and national security, protective services

      • Prevention of a serious threat to health or safety

      • Limited information for a facility directory and to clergy

  • We are required by law to disclose health information to the following people:

    • To You or Your Personal Representative

    • To the Secretary of the U.S. Department of Health and Human Services upon request

  • Other uses or disclosures of your health information may be made with your written authorization.

  • Revised 11/04 from RLS & MKS HIPAA Form 1.3 v2 4/14/03


Advance directives living will and designation of health care surrogate

As a patient, you have the right to formulate Advance Directives and to make decisions concerning your medical care, including the right to accept or refuse medical/surgical treatment. The Roy Lester Schneider Hospital is committed to helping facilitate your expressed wishes concerning your health care. Our hospital will honor your directive within the limits of the law and our mission, vision, and values. You will receive the same medical treatment from Roy Lester Schneider Hospital whether or not you have signed an Advance Directive.

Advance Directives are legal documents that you may complete to help ensure that your wishes are carried out when you are unable to speak for yourself. These documents indicate your choices regarding health care decisions, including, but not limited to, life-prolonging procedures and the designation of someone to make health care decisions in the event you would be unable to make decisions for yourself. Advance Directives are commonly known as the Living Will and Designation of a Health Care Surrogate.

The Living Will is an Advance Directive Document that allows you to indicate your choices regarding the use of life-prolonging procedures.

According to law, when two physicians certify that you have either a terminal condition, end-stage condition or are in a persistent vegetative state, your Living Will can be honored. Your may also designate a person to make health care decisions for you if you become mentally or physically unable to do so yourself. This may be done by completing a Designation of Health Care Surrogate document. It is very important that your wishes expressed in these documents be discussed with your physician and family / significant other.

We would like to request that each time you come to the hospital to be admitted as an inpatient that you bring a copy of your most recently completed Advance Directives. During your admittance, as an adult inpatient, you will be asked if you have completed an Advance Directive. Your response will be documented in your medical record. If you have already signed an Advance Directive document and didn’t bring it to the hospital, you will be asked to complete another.

You may request Advance Directive forms from the Admitting Department or designated employee, or your nurse.

Advance DirectivesLiving Will and Designation of Health Care Surrogate


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