Attachment E - 1.docx

Attachment E VA-VISN 12 VETERAN RIGHTS AND RESPONSIBILITIES (R&R) (1 of 2)

Patient Name: _____________________________________Last 4 SN__________DOB:___________ As a patient of the Veterans Affairs Medical Center, you have the RIGHT to:

· Be treated with appropriate, considerate, respectful and courteous care.

· Discuss with our staff your concerns or issues pertaining to the quality of services and/or devices furnished to you.

· Express your concerns regarding the timeliness of services and devices provided.

· Discuss your eligibility and entitlement to Prosthetic Services with staff personnel.

· Privacy; to refuse to take part in any research studies.

· Complete, and have placed on file, a copy of your Patient Satisfaction Form clearly stating your questions and concerns.

· Receive a response to a written complaint in a timely manner.

· Refuse treatment/equipment and knowingly refuse to be provided care and equipment to treat your condition.

· Appeal any decision made by the Prosthetic & Sensory Aids Service concerning your eligibility and entitlement to receive such services or equipment.

As a patient of the Veterans Affairs Medical Center, you have the RESPONSIBILITY to:

· Treat VA and home oxygen supplier employees with respect and courtesy.

· Take reasonable care when using devices and/or appliances issued to you.

· Exercise reasonable care and maintenance of devices and appliances issued to you.

· Immediately advise the Prosthetic &Sensory Aids Service of defective equipment.

· Advise your clinician at the VA Medical Center when equipment is no longer required for your use.

· Not sell or give away any equipment provided to you by the Department of Veterans Affairs.

· Comply with the prescribed plan of treatment, and to communicate any concerns or health care needs with health care providers.

As a Respiratory Patient of the VA Medical Center, you have the RESPONSIBILITY to:

· Allow the home oxygen supplier employees to make home visits on a regular basis.

· Immediately advise the home oxygen supplier of any problems with your oxygen equipment or if you have any health concerns.

· If urgent assistance is needed related to your condition, please go to nearest urgent care or dial 911.

I understand that my signature on this agreement authorizes any entity with medical information regarding me, to release to Company any information regarding my medical history, treatments or other relevant medical information. I understand that my signature on this agreement authorizes Company to release my Company medical records to: any authorized representative of certain local, state, or national licensing, credentialing or accrediting boards or bodies, such as The Joint Commission, certain local, state, and national entities, as well as certain public utilities, for Emergency Preparedness planning purposes.

This release specifically includes the release of my clinical records. I understand that I have the right to refuse to release my medical records, and that by signing this agreement, I waive that right. This consent is valid for whatever time-period is reasonably necessary for these authorized representatives to complete these tasks and shall remain in effect until such time as I revoke it in writing. The revocation will have a prospective application only.

VA 1624 Clinical Respiratory Assessment – Vent (VISN 12) Rev 6/4/2020