Summit Endoscopy Center, LLC

1265 Highway 54 West Suite 401 Fayetteville, GA 30214

Patient Rights and Responsibilities

Summit respects and supports your rights as a patient, recognizing that each patient is an individual with unique health care needs. Because of the importance of respecting each patient's personal dignity, we provide considerate, respectful care focused upon the patient's individual needs. Summit affirms the patient's right to make decisions regarding his or her medical care including the decision to discontinue treatment, to the extent permitted by law.

1. The privacy of all patients will be respected at all times. Patients will be treated with
respect,consideration and dignity.

2. Patients will receive assistance in a prompt, courteous and responsible manner.

3. Patients medical records are considered confidential. Except as otherwise required by law,
patient records and/or portions of records will not be released to outside entities or
designated representatives without expressed written approval.

4. Patients have the right to know the identity and status of individuals providing services to them.

5. Patients, or legal authorized rerepresentatives, have the right to thorough, current and
understandable information regarding their diagnosis, treatment options and prognosis, if
known, and follow-up care. All patients will sign informed consent forms after all information .
has been provided and their questions answered.

6. Patients have the right to refuse treatment and to be advised of the alternatives and
consequences of their decisions. Patients are encouraged to discuss their
objectives with their provider.

7. Patients have the right to refuse participation in experimental treatment and procedures.
Should any experiental treatment be considered, it will be fully explained to the patient prior to

8. Patients have the right to express complaints about the care they have received and to submit
their grievance to the Administrator. The Administrator will complete and "Incident Report"
and bring the issue to the attention of the Medical Director in a timely manner so the
grievance may be addressed. Patients have the right to file a grievance with the Composite
State board of Medical Examiners concerning the physician, staff, center and/or treatment
received. (See address and numbers below.)

9. Patients have the right to be provided with information regarding emergency and after -hour

10. Patients have the right to obtain a second opinion regarding the recommended procedure.
Responsibility for the expense of the second opinion rests solely with the patient.

11. Patients have the right to a safe and pleasant environment during their stay.

12. Patients have the right to be provided with informed consent forms as required by the laws of
the State of Georgia.

Patient Responsibilities

1. Patients are expected to provide complete and accurate medical histories including providing
information on all current medications, keep all scheduled pre and post-procedure
appointments and comply with treatment plans to help ensure appropriate care.

2. Patients are responsible for reviewing and understanding the information provided by their
Physician or nurse. Patients are responsible for understanding their insurance coverage and
the procedures required for obtaining coverage.

3. Patients are responsible for providing insurance information at the time of service and to notify
the receptionist of any changes in information regarding their insurance or medical information.

4. Patients will be provided, upon request, all available information regarding services available at
the Office and the Center, as well as information about the estimated fees and options for

5. Patients are responsible for paying all charges for co-payments, co-insurance, deductible and
the full fee for non-covered services at the time of, or prior to, the procedure unless other
arrangements have been made in advance with the Billing Office.

6. Patients are responsible for treating Physicians and Staff in a courteous and respectful

7. Patients are responsible for asking questions about their medical care and for seeking
clarification from their physician of the services to be provided until they fully understand the
care they are to receive.

8. Patients are responsible for following the advice of their provider and for considering the
alternatives and/or likely consequences if they refuse to comply.

9. Patients are responsible for expressing their opinions, concerns or complaints to the
appropriate personnel in a constructive manner.

10. Patients will provide a driver who will come and stay in the waiting room while the procedure is performed and transport the patient home after the recovery period.

To access GA Complaint Unit: Heath Care Facility Regulation Division,
Suite 3100 Complaint Intake Unit,
2 Peachtree St. NW, Atlanta, GA 30303  404-657-5726  or 404-657-5728 or 1-800-878-6442
To contact the Federal Meicare Office of Ombudsman call 1-888-734-3247
Office of Ombudsman   409 3rd Street, SW Suite 7125  Washington, DC  20416
United States
Fax:  202-481-5719
TTY/TTD: 800-877-8339
Tol Free: 888-734-3247
Website for Medicare Beneficiary Ombudsman:
Website Builder