Pecos County Memorial Hospital
387 West IH-10
Fort Stockton, TX 79735
432-336-2004
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SERVICES

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Patient Rights

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy:

You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must complete an Authorization for Release of Patient Information. This form may be obtained from the Health Information Department of the hospital. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. The Health Information Management Department of the hospital will assist you in this process. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Pecos County Memorial Hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend:

If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Pecos County Memorial Hospital.

To request an amendment, your request must be made in writing. Contact the Privacy Officer for the correct form used to submit this written request. In addition, you must provide a reason that supports your request (space is provided on the correct form).

We may deny your request for an amendment if it is not in writing, or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

Is not part of the medical information kept by or for Pecos County Memorial Hospital;

Is not part of the information which you would be permitted to inspect and copy; or

Is accurate and complete.

Right to an Accounting of Disclosures:

You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about care you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the waiting room. The notice will contain on the first page, at the top, the effective date. In addition, each time you register at the front desk for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Pecos County Memorial Hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the Pecos County Memorial Hospital, contact the Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time (contact the Privacy Officer for the proper form). If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you under the limits of the law.

It is the goal of the Customer Representative to assist all patients during their hospital stay, serving as liaison between patients, family members, guests, the hospital personnel and medical staff. The Customer Representative strives to use patient feedback in assisting the hospital to identify and act upon suggestions and to resolve specific problems as they arise. Should you have a concern about your care or ethical issues here at Pecos County Memorial Hospital, please contact our Customer Representative at 432-336-2004 or contact the operator and ask to speak with the House Supervisor.

After hours, weekend and holidays contact the operator and ask to speak with the House Supervisor.

If your concern is not resolved or you feel you need to express your concern to an entity other than the Hospital, call the Texas Department of Health at 432-336-7506.

Pecos County Memorial Hospital will not deny or discriminate against any person in need of medical treatment based on race, color, creed, national origin, age, health condition, or source of payment.

Upon your arrival at PCMH, you will be asked to provide any and all pertinent information needed for your medical records. An admitting representative will assist you in completing the necessary forms for admission.

Regulatory agencies require the hospital to inform all patients of their rights and responsibilities and to obtain signatures from each patient or the next of kin for all treatment and/or surgical procedures. A parent or guardian must sign all permits for children under the age of 18.

Discharge notices are originated at the nursing stations on each level. This notice must be received in the Admissions Office from Nursing Service before discharge procedures may be initiated.

Family members or the patient if needed will be sent to Admissions to be cleared for dismissal. Any finalization of necessary information, paperwork and financial arrangements will be made at this time. The patient or family member will be given the dismissal slip, to present to the Nursing Staff.

All patients should familiarize themselves with the terms of their insurance coverage. This will help you understand the hospital's billing procedures and charges. If there is a question about your insurance coverage, a member of the Admission Department or Business Office Department will contact you or a member of your family while you are here. Information is needed in order to process your claims.

If You Have Health Insurance

We will need a copy of your identification card. We also may need the insurance forms which are supplied by your employer or the insurance company. You will be asked to assign benefits from the insurance company directly to the hospital.

If You Are a Member of an HMO or PPO

Your plan may have special requirements, such as a second surgical opinion or pre-certification 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 in the hospital. Some physician specialists may not participate in your healthcare plan and their services may not be covered.

A Utilization Management nurse will be reviewing your chart and relaying pertinent information to your insurance company, PPO, or HMO, if you have signed the release of information form. Your insurance company decides on a day to day basis if your stay is medically necessary according to their criteria. Even if they give approval, this does not guarantee payment. The nurse will stay in contact with your insurance company during your hospital stay to help make sure all services are covered. If any services are denied, the nurse will initiate an appeal with the company. You may be responsible for any remaining charges.

If You Are Covered by Medicare

We will need a copy of your Medicare card to verify eligibility and process your Medicare claim. You should be aware that the Medicare program specifically excludes payment for certain items and services, such as cosmetic surgery, some oral surgery procedures, personal comfort items, hearing evaluations and others. Deductibles and co-payments also are the responsibility of the patient. Additionally, Medicare will only pay for a semi-private room. If you requested a private room, you must pay the difference.

If You Are Covered by Medicaid

We will need a copy of your Medicaid card. Medicaid also has payment limitations on a number of services and items. The Texas Medicaid programs pays for allowable charges not to exceed 30 days. Medicaid does not pay for a private room, take-home drugs or other personal items. If you request any of these services, you must pay the difference.

Your Hospital Bill

The hospital is responsible for submitting bills to your insurance company and will do everything possible to expedite your claim. But 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.

A claim will be sent directly to your insurance company. This statement will include charges for your room and other services such as medication, laboratory testing and operating room. Managed care contracts, Medicaid and authorized Workers' Compensation laws prohibit us from sending statements to patients except where any co-pay amounts or for any non-covered services that have been provided. Managed Care contracts allow the hospital to bill for any co-pays, deductible, and for non-covered services that have been provided. In this case, you will receive a statement only for the non-covered services.

In addition to the copy of the hospital statement, you will receive separate bills from your private physician and from other physicians whose services you required. For example, you may receive a bill from the radiologist who interpreted your X-ray films, or from the pathologist who performed or interpreted the more sophisticated laboratory procedures you received.

Pecos County Memorial Hospital recommends that all valuables and personal belongings are sent home at time of admission. Personal belongings that are brought in should be kept at a minimum. Pecos County Memorial Hospital cannot accept responsibility for loss or theft unless the valuables or belongings are placed in the safe for safekeeping.

As a condition of participation in the Medicaid disproportionate share program, this hospital will provide care to persons who are unable to pay for their care.

In order to be eligible for charity care, you must:

Have no other source of payment such as insurance, government assistance, or savings; or

Have hospital bills beyond your financial resources;

Return this application to Krystal Barriga in Patient Accounts with all required supporting documents which are outlined in the application.

Forms and information about applying for charity care are available upon request.

REGLAS PARA SERVICIOS DE CARIDAD

Este hospital participa en u program de Medicaid, llamado " Disproportionate Share Program". Como condicion a esta participacion, el hospital ofrece servicios gratuitos a personas que no pueden pagar por su atencion medica.

Para tener derecho a servicios caritativos, se necesita tener los siguientes requistos:

No contra con otro medio de pagar, (seguro medico, asistencia del gobierno federal, o sus proios ahorros o bien)

Tener cuentas de hospital que esten mas all de sus economicos.

Presentar pruebas de sus ingresos y recursos economicos,

Lienar la solicitud de servicio y dar la informacion que le pida el hospital.

A pedido de los interesados, se proveeran formularios y informacion y datos tocante a la solicitacion de servicios caritativos.

This health care facility is required by law to make its services available to all people in the community. This facility is not allowed to discriminate against a patient because of race, creed, color, national origin, because a patient is covered by a program such as Medicaid or Medicare.

If this facility provides emergency services it must not deny those services to a person who needs them but cannot pay for them.

If you have been improperly denied services contact the admissions of Business Office of this facility.