Delivery Ticket | WONACE DME

PATIENT BILL OF RIGHTS AND RESPONSIBILITIES: To ensure the finest care possible, as a Patient receiving Durable Medical Equipment (DME) and our Facility services, you should understand your role, rights, and responsibilities involved in your own plan of care. Patient Rights: To select those who provide you with DME and Facility services. To receive the appropriate or prescribed services in a professional manner without discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference, or physical or mental handicap. To be treated with friendliness, courtesy, and respect by each and every individual representing our Facility, who provided treatment or services for you and be free from neglect or abuse, be it physical or mental. To assist in the development and preparation of your plan of care that is designed to satisfy, as best as possible, your current needs, including the management of pain. To be provided with adequate information from which you can give your informed consent for the commencement of services, the continuation of services, the transfer of services to another health care provider, or the termination of services. To express concerns, and grievances, or recommend modifications to your DME and Facility services, without fear of discrimination or reprisal. To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments, risk of treatment, or care plans. To receive treatment and services within the scope of your plan of care, promptly and professionally, while being fully informed as to our Facility’s policies, procedures, and charges. To request and receive data regarding treatment, services, or costs thereof, privately and with confidentially. To be given information as it relates to the uses and disclosure of your plan of care. To have your plan of care remain private and confidential, except as required and permitted by law. Patient Responsibilities: To provide accurate and complete information regarding your past and present medical history. To agree to a schedule of services and report any cancellation of scheduled appointments and/or treatments. To participate in the development and updating of a plan of care. To communicate whether you clearly comprehend the course of treatment and plan of care. To comply with the plan of care and clinical instructions. To accept responsibility for your actions, if refusing treatment or not complying with, the prescribed treatment and services. To respect the rights of Facility personnel. To notify your Physician and the Facility of any potential side effects and/or complications

WONACE DME Delivery Ticket

ACKNOWLEDGEMENT OF RECEIPT (Proof of Delivery)