Patient Information and Forms

Patients Rights

We respect the dignity and pride of each individual we serve. We comply with applicable Federal civil rights laws and do not discriminate on the basis of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state, or local law. Each individual shall be informed of the patient's rights and responsibilities in advance of administering or discontinuing patient care.

Respetamos la dignidad y el orgullo de cada persona que atendemos. Cumplimos con las leyes y derechos civiles federales y no discriminamos por cuestiones de edad, sexo, discapacidad, raza, color, ascendencia, ciudadanía, religión, embarazo, orientación sexual, identidad o expresión de género, nacionalidad, estado de salud, estado civil, condición de veterano, fuente o capacidad de pago o cualquier otra causa prohibida por la ley federal, estatal o local. Cada individuo será informado de los derechos y las responsabilidades del paciente antes de administrar o discontinuar la atención del paciente.

Patient Responsibilities

The care a patient receives depends partially on the patient him/herself. Therefore, in addition to the above rights, a patient has certain responsibilities. These should be presented to the patient in the spirit of mutual trust and respect.

To provide accurate and complete information concerning his/her health status, medical history, hospitalizations, medications and other matters related to his/her health
To report perceived risks in his/her care and unexpected changes in his/her condition to the responsible practitioner
To report comprehension of a contemplated course of action and what is expected of the patient, and to ask questions when there is a lack of understanding
To follow the plan of care established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician's orders
To keep appointments or notifying the facility or physician when he/she is unable to do so
To be responsible for his/her actions should he/she refuse treatment or not follow his/her physician's orders
To assure that the financial obligations of his/her healthcare care are fulfilled as promptly as possible
To follow facility policies, procedures, rules and regulations
To be considerate of the rights of other patients and facility personnel
To be respectful of his/her personal property and that of other persons in the facility
To help staff to assess pain, request relief promptly, discuss relief options and expectations with caregivers, work with caregivers to develop a pain management plan, tell staff when pain is not relieved, and communicate worries regarding pain medication
To inform the facility of a violation of patient rights or any safety concerns, including perceived risk in his/her care and unexpected changes in their condition
To provide a responsible adult who, in accordance to the surgery center's directives, will remain at the facility for the duration of his/her stay, transport him/her home from the facility and remain with him/her for the initial 24 hours after surgery/anesthesia, if required by his/her physician

Admissions

The patient or responsible party should bring their insurance card(s) and a photo ID.
The patient or responsible party should bring their preferred payment method for any co-pays or balances.
The patient or responsible party should review carefully all of their information as listed on the chart. Spellings, addresses, and other demographic information should be reviewed.
All patients should have a ride home and a responsible adult to care for them that evening. For patient safety, we request that a responsible adult remain at the center with the patient at all times.
Parent(s) or legal guardians of pediatric patients (17 years of age or younger) need to remain at the Center at all times until dismissal. Legal guardians should bring with them any legal or guardianship papers.
If you have a Latex allergy, or think you may be pregnant, please call the surgical center at (316) 334-1500 to speak to the pre-op assessment coordinator.

Advanced Directives

Advance directives include written or verbal directions a patient gives in advance to state choices for health care or name someone to make those choices for the patient if the patient is unable to make decisions for himself/herself. A living will states what kinds of medical treatments would be acceptable at the end of life. You can find DPOA forms and Living Will forms below.

If a patient, who is to receive a procedure at the facility, presents the staff with a living will, the patient must be advised that the policy is to always attempt to resuscitate and to transfer any patient requiring resuscitation or emergency care to the hospital. The hospital can then determine when to implement the living will.

Reporting Major Concerns

To report a patient rights concern, please contact any of the following:

RN Clinical Director

Erin Schueller, RN, BSN

1540 N Lindberg Circle

Wichita, KS 67206

Phone: (316) 334-1500

State Reporting Agency

Kansas Dept. of Health and Environment, Health Facilities Program

1000 SW Jackson Street, Suite 330

Topeka, KS 66612

Phone: (785) 296-1258

Contact

Medicare Ombudsman

File a complaint at Medicare.gov

Accrediting Organization

The Joint Commission

1 Renaissance Blvd.

Oakbrook Terrace, IL 60181

General inquiries: (630) 792-5800