Ambulatory Surgery Center Patient Bill of Rights

Patient rights will be exercised without regard to sex, culture, economic, educational, or religious background or the source of his or her background or the source of payment for care.

Patients can expect:

• Considerate and respectful care.
• Appropriate privacy.
• Patient disclosures and individual medical records are confidential and secure, except when
  required by law for reporting purposes. Patients have the right to sign a waiver of release if they so
  choose.
• Patients and/or a designated individual by the patient or legally responsible persons are provided, to
  the degree known, with complete information concerning diagnosis, evaluation, treatment and
  prognosis.
• Patients are given the opportunity to participate in decisions involving their health care.
• Information is available to patients and staff regarding:
  • Patient rights. Please refer to the Section 151:21 NH Patients' Bill of Rights website.
  • Patient conduct and responsibilities.
  • Provisions for After Hours and Emergency Care. Please call the appropriate number below and the provider on call will respond:
    • Manchester: 603-695-2500
    • Nashua: 603-577-4801
  • Fees for Services - call 800-238-0505.
  • For payment arrangements or to request financial assistance, call 844-808-0730.
  • Right to refuse to participate in experimental research.
  • Advance Directives
  • Credentials of healthcare providers will be offered on request.
• Patients have the right to change providers if another qualified provider is available.
• Patients are informed about process of expressing suggestions, complaints, compliments, or
  grievances.
• To contact Patient Relations, call 603-629-1859.
• Patient has the right to be free of all abuse or harassment.
• Patient has the right to be fully informed about the treatment, procedure and expected outcome
  prior to procedure.
• If a patient is adjudged incompetent under applicable state health and safety laws by the court, the
  rights of the patient are exercised by the person appointed under state law to act on the patient’s
  behalf.
• If a court has not adjudged a patient as incompetent, any legal representative designated by the
  patient may exercise the rights of the patient to the extent allowed by law.
• A patient has the right to his or her rights without being subjected to discrimination or reprisal.
• Patients have the right to choose another facility for their care.
• Our providers do not have a personal financial interest in the Ambulatory Surgery Center at Dartmouth Hitchcock Clinics Manchester.

Patient responsibilities

Patients must:

• Give accurate information about medical conditions, medications (including over-the-counter products), dietary supplements and allergies.
• Follow the agreed-upon treatment plan recommended by your provider and participate in your care.
• Provide a responsible adult to transport you home and to remain with you as directed by your provider or as indicated on discharge instructions. You may not drive at all after a procedure if you have received sedation or anesthesia.
• Inform staff of a living will, medical power of attorney or advance directive that could affect your care. It is advisable to have these documents scanned into the medical record for future use if needed. For more information, please visit our Advance Care Planning page.
• Accept personal responsibility for charges not covered by insurance.
• Be respectful of all health care providers and staff, as well as other patients.
• Inform staff members of any special needs or accommodations that may be necessary.
• Be responsible for your actions if you refuse treatment or do not follow the provider’s instructions.

Grievance policies and procedures

If you believe that Dartmouth Hitchcock Clinics Manchester or Dartmouth Hitchcock Clinics Nashua has failed to provide these services or discriminated in another way based on race, color, national origin, age, disability or sex, you can file a grievance. Dartmouth Hitchcock Clinics Manchester and Dartmouth Hitchcock Clinics Nashua has adopted grievance procedures that provide for the prompt and equitable resolution of complaints.

To voice concerns or grievances regarding your care, please contact:

Heather Long, Director of Perioperative Services
Dartmouth Hitchcock Clinics Southern Region
100 Hitchcock Way
Manchester NH 03101
603-629-1800

For Medicare and Medicaid patients

• All Medicare beneficiaries may file a complaint with the Medicare Beneficiary Ombudsman at 800-633-4227 or write them at the Ombudsman Center.
• Center of Medicare and Medicaid Services
  7500 Security Boulevard
  Baltimore, MD 21244

For more information, please refer to the Dartmouth Hitchcock Medical Center and Dartmouth Hitchcock Clinics Patient Rights and Privacy web page.