Ambulatory Surgical Center Locations:

Main Campus
2727 West Holcombe Blvd.
3rd Floor Suite 10015655
Houston, Texas 77025

Spring Medical and Diagnostic Center
Cypress Woods Medical Dr.
Houston, Texas 77014
713-442-0000 (713) 442-1700

PATIENT RIGHTS

Kelsey-Seybold Clinic Ambulatory Surgical Centers will provide access to treatment or
accommodations that are available or medically indicated without regard to race, creed, sex,
nationality, gender, disability, age, or source of payment.

You are entitled to safe, considerate, respectful and dignified care at all times. This includes your right
to:

• Receive care in a safe setting, free from any form of abuse or harassment.
• Receive appropriate assessment and effective pain management.
• Receive respectful consideration and care with recognition of personal values and belief systems.
• Wear appropriate personal clothing or religious, cultural or other symbolic items that do not interfere
  with recommended diagnostic procedures or treatment.

You are entitled to personal and informational privacy as required by law. This includes your right to:

• Refuse to talk with or see anyone not officially connected with the clinic, including visitors or persons
  officially connected with the clinic but not directly involved with your care.
• Request a person of your own gender present during physical examination, treatment, or procedure
  performed by a health professional of the opposite gender.
• Refuse to remain disrobed any longer than is required for accomplishing the medical purpose for which
  you were asked to disrobe.
• Be interviewed and examined in surroundings designed to assure reasonable visual and auditory
  privacy.
• Expect that any discussion or consultation involving your case should be conducted discreetly and that
  individuals not directly involved in your care should not be present without your permission.
• Know the identity, credentials, professional status, role and financial and/or business relationship of all
  those involved in your care.
• •  NOTE: The Ambulatory Surgical Centers are owned by Kelsey-Seybold Medical Group, PLLC, and
    some of the physicians and surgeons practicing in the ASC are members of the Medical Group.

You are entitled to confidentiality regarding disclosures and records. This includes your right to:

• Have your medical record read by individuals directly involved in your treatment, in the monitoring of its
  quality, with your written authorization, or by those who have legal custody, or other authorized
  individuals.
• Expect communications and records pertaining to your care, including the source of payment for
  treatment, to be treated as confidential.
  

You are entitled to be involved in all aspects of your care and to participate in decisions involving your
care, except when such participation is contraindicated for medical reasons. (When it is not medically
advisable to give such information to the patient, the information should be available to a legally
authorized individual.) This includes your right to:

• Obtain complete and current information concerning your diagnosis, to the degree known, evaluation,
  treatment, and prognosis.
• Know who is responsible for coordinating your care and authorizing and performing your procedures or
  treatment.
• Be informed with a clear, concise explanation of your condition and of the appropriate treatment
  options, including their risks and benefits, alternative treatment options, the consequences of no
  treatment, and the results of medical care provided – including any unanticipated adverse outcomes.
• Consult with another physician or specialist in order to obtain a second opinion regarding your condition
  or treatment at your own expense or consistent with your health plan coverage.
• Refuse treatment to the extent permitted by law. When refusal of treatment prevents the provision of
  appropriate care in accordance with professional standards, the relationship may be terminated upon
  reasonable notice.
• Refuse to undergo involuntary treatment or be subjected to research or experimental procedures
  without your written consent, or that of your legal representative.
  

You are entitled to information regarding Transfers, Continuity of Care, Provisions for after-hours Care
and Emergency Care. This includes your right to:

• Receive a complete explanation regarding the necessity for the transfer and of the alternatives to such
  transfer.
• Be informed by the practitioner responsible for your care, or their delegate, of any continuing health
  care requirements following discharge from the clinic.
• Expect plans for reasonable continuity of care after discharge so that continuing health care needs may
  be met.
• Be informed of provisions for after-hours care such as: Physician Call Rotation, After-Hours Nurse
  Triage, Answering Service, Referrals to Emergency Department, and Weekend Clinics.

You are entitled to receive and examine an explanation of all bills regardless of the source of payment.
This includes your right to:

• Request a cost estimate of a proposed medical service. If you are an uninsured or indigent patient you
  may request information about discounts for medical services.
• Request and receive an itemized and detailed explanation of your total bill for services rendered in the
  Ambulatory Surgical Centers.
• Timely notice prior to termination of your eligibility for reimbursement by a third-party payer for the cost
  of your care.

You are entitled to have an advance directive, as required by state or federal law and regulations. This
includes your right to:

• Obtain information regarding an advance directive.
• Formulate advance directives, to appoint in writing a durable power of health care attorney, or by
  operation of law to have a surrogate decision-maker to make health care decisions on your behalf to
  the extent permitted by law.
• Have your advance directive (if you have one) included in your medical record.
• Have your advance directive followed to the extent that is medically appropriate and lawful.
• • NOTE: Because we provide surgery and procedures that are considered to be elective, our policy
    states that it is medically appropriate to initiate resuscitative or other stabilizing measures and
    transfer you to an acute-care hospital for further evaluation. At the acute-care hospital, further
    treatments or withdrawal of treatment measures already begun will be ordered in accordance with
    your wishes, Advance Directive, or Healthcare Power of Attorney. If you do not agree with the
    organization’s policy on Advance Directives, we will assist you with rescheduling your procedure.
    

You are entitled to effective communication in a language and manner that you understand. This
includes your right to:

• Have access to an interpreter (within reason), at no cost to you, if you are not fluent in English.
• Kelsey-Seybold Clinic will assist with the arrangements to provide, as a courtesy, non-English speaking
  patients with physicians and/or staff that speak your language. (If this is not possible, Kelsey-Seybold
  Clinic should refer non-English speaking patients to Masterword Services, which provides medical
  interpreters in their language. Non-English speaking patients may elect to obtain a preferred
  discounted rate by calling 281-589-0810. The fee may be authorized for payment at Clinic expense in
  urgent situations at the discretion of the Medical Director, Section Chief, Managing Physician and/or
  designee).
• Have access to auxiliary aids and assistive animals if you have an impairment which requires use of
  these. In accordance with the Americans with Disabilities Act (ADA), Kelsey-Seybold Clinic should
  provide, at no cost, a sign language interpreter upon request.

You are entitled to information about the rules and regulations of the Kelsey-Seybold Clinic
Ambulatory Care Centers’ that are applicable to your patient care and conduct.

You are entitled to information about the clinic mechanisms for the initiation, review, and resolution of
patient complaints. This includes the right to:

• Be informed of procedures for expressing suggestions, complaints, and grievances, including those
  required by state and federal laws.
• Express dissatisfaction regarding the quality of care without subjected to discrimination, reprisal or
  jeopardizing future care.

Grievances can be voiced or filed with the following:

ASC Director
Kelsey-Seybold Clinic
2727 W. Holcombe Blvd.
Houston, TX 77025
713-442-3300

Paula Moore, Admin Assy. IV
PQCU-MC 1979
Texas Dept. of State Health Services
P.O. Box 149347
 Austin, TX 78714-9347
(p) 1-888-963-7111 (f) 512-834-6653

Office of Medicare Beneficiary Ombudsman
www.medicare.gov
1-800-Medicare (1-800-633-4227)

You are encouraged to promote your own safety by becoming an active, involved and informed
member of your health care team. This includes your right to:

• Ask questions if you are concerned about your health or safety.
  Verify your site/side of the body that will be operated on prior to the procedure.
• Remind staff to check your ID before medications are given, blood samples are obtained or prior to an
  invasive procedure.
• Remind the care-givers to wash their hands prior to giving care.
• Be informed about which medications you are taking and why you are taking them.
• Look for an identification badge to be worn on all Kelsey-Seybold Clinic Ambulatory Surgical Centers
  employees.

PATIENT RESPONSIBILITIES

Provide complete and accurate information to the best of your ability about your health, any
medications, including over-the-counter products and dietary or herbal supplements and any allergies
or sensitivities. This includes your responsibility to:

• Provide, to the best of your knowledge, accurate and complete information about present complaints,
  past illnesses, hospitalizations, medications including: over-the-counter products, dietary supplements,
  herbal supplements, allergies or sensitivities, and other matters relating to your health.
• Report unexpected changes in your condition to the responsible practitioner.
• Report whether you did not comprehend the contemplated course of action and what is expected of
  you.
• Inform your physician or health care provider about any living will, medical power of attorney, and/or
  advance directive.

Follow the treatment plan prescribed by your provider. This includes your responsibility to:

• Follow the treatment plan recommended by the practitioner responsible for your care or other members
  of the healthcare team. This may include following the instructions of nurses and allied health
  personnel as they carry out the coordinated plan of care, implement the responsible practitioner’s
  orders, and enforce the applicable Ambulatory Surgical Center’s rules and regulations.
• Keep to appointments and, when you are unable to do so for any reason, you are responsible for
  notifying the primary practitioner or the Ambulatory Surgical Center.

Notify the Ambulatory Surgery Center of your refusal of treatment. This includes your responsibility
to:

• Accept responsibility for your actions if you refuse treatment or decide not to follow the practitioner’s
  professional medical instructions.

Observe the Ambulatory Surgery Centers’ Rules and Regulations. This includes your responsibility to:

• Follow the rules and regulations affecting your patient care and your conduct.
  Assure that the financial obligations of your health care are fulfilled as promptly as possible.
• Be aware of your health plan’s limitations, benefits, requirements, and your assigned Primary Care
  Provider (PCP) if your plan assigns a PCP. You are responsible for all charges if any services are not
  covered by insurance. Verification of benefits is not a guarantee of payment by your insurance
  company.
• Arrive on time for your appointments. When preparations for specific tests and procedures are
  required, be certain you have completed those preparations. If you must cancel an appointment, do so
  in time for another patient to use your appointed time (24 hours notice is best, but we appreciate
  receiving notice as short as one hour.)
• Treat your physicians and all your caregivers with the same respect and courtesy you expect from
  them. Threats, swearing and abusive language will not be tolerated and may result in removal from the
  premises.
• Be considerate and respectful of the rights of other patients and personnel and for assisting in the
  control of noise, smoking, and the number of visitors.

Arrange Transportation. This includes your responsibility to:
Provide a responsible adult to transport you from the facility and remain with you for 24 hours if
indicated.