Patient Rights and Responsibilities
All patients have the right to:
• Ask questions
• Accessible health care
• Respect and dignity
• Information regarding status, care
• Notification of admission to family,
physicians and others
• Consent of treatment
• Participation in plan of care
• Make informed decisions regarding care
• Formulate advance directives
• Management of pain
• Request of refusal of treatment
• Personal privacy
• Confidentiality of clinical records
• Protected health information
• Access to clinical records
• Identity of care givers
• Personal safety
• Communication in your preferred language
• Freedom from abuse or harassment
• Freedom from seclusion and restraint
• Transfer to another facility for additional
service if needed, and continuity of care
• Receive an explanation of bill
• Access to hospital rules and regulations
• Be free from discrimination
All patients have the responsibility to:
• Provide accurate information
• Ensure financial arrangements
• Respect rights of others
• Follow their care / treatment plan
• Take responsibility for outcome when care /
treatment plan is not followed
• Follow hospital rules and regulations
• Ask questions
Hospital Bills and Insurance
If You Have Health Insurance
Your plan may have special requirements, such as a second surgical option
or precertification for certain tests or procedures. It is your responsibility
to make sure the requirements of your plan have been met. If your plan’s
requirements are not followed, you may be financially responsible for
all or part of the services rendered at the hospital. Some physician specialists
may not participate in your health care plan. Please check with your physician
to ensure they are a participating provider in your plan.
Your Health Insurance Plan
We will need a copy of your Medicare card, and a photo ID may be required
to verify eligibility and process your claim. You should be aware that
the Medicare program specifically excludes payment for certain items and
services, such as some oral surgery procedures.
If You Are Covered By Medicare
We will need a copy of your Medicaid card and photo ID may be required.
Medicaid also has payment limitation.
If You Are Covered By Medicaid
A representative from the Patient Accounts Department will discuss financial
arrangements with you. Financial assistance is available to qualifying
patients that do not qualify for other outside assistance programs.
If You Have No Health Insurance
The hospital will submit your claim to your insurance company and will
do everything possible to expedite your claim. You should remember that
your policy is a contract between you and your insurance company, and
you have the final responsibility for payment of your hospital bill. We
have several payment options available to assist you in paying your bill.
If you have certain tests or treatments in the hospital, you may receive
a bill from physicians you did not see in person. These bills are for
professional services rendered by these doctors in diagnosing and interpreting
test results while you were a patient. Pathologists, radiologists, cardiologists
and other specialists perform these services.
Notice of Health Information Privacy Practices
The notice of Health Information Privacy Practices describes the patient’s
rights and certain obligations regarding the use and disclosure of medical
information. This notice is provided to the patient at the time of registration.
The staff, Board of Governors, physicians and administration of Good Samaritan
are committed to providing quality health care for you and your family.
If you have concerns related to the overall quality of your care or safety,
please call 812-885-3195. If you should require additional follow-up,
you may contact The Joint Commission on their website at www.jointcommission.org
or call 800-994-6610.
Patient Concern Resolution Process
Good Samaritan has an established Patient Concern Resolution Process. Concerns
should be brought to the attention of the Nurse Manager or Director of
the involved unit, the Patient and Family Representative or Hospital Administration.
Unresolved concerns will be handled by the Patient Concern Grievance Committee.
A grievance may be lodged with the Indiana State Department of Health,
regardless of whether or not the patient has first used the hospital’s
Patient Concern Resolution Process. The address and phone number of the
Indiana State Department of Health are:
Indiana State Department of Health
2 North Meridian Street | Section 4-A
Indianapolis, Indiana 46204
Home Care Services: 1-800-227-6334