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<p style="text-align: center;"><u>PATIENT RIGHTS AND RESPONSIBILITIES</u></p>
YOU HAVE THE RIGHT TO:
<ul>
 	<li>Professional, committed, quality services without regard to race, religion, gender, ethical background, age, sexual orientation, physical disability, employment status, insurance coverage or any other non-clinical reason. You may request services from someone with training or experiences from a specific cultural, spiritual, or gender orientation. If these services are not available, we will assist you in the referral process.</li>
 	<li>Receive humane and dignified treatment, with respect for your right to privacy, in an environment free of discrimination, sexual harassment and/or abuse;</li>
 	<li>Be treated in accordance with a specialized treatment plan. You have the right to participate, with your clinician, in the development of your treatment plan and in decisions that will establish your treatment goals;</li>
 	<li>Be informed about all program policies which will affect the course of your treatment;</li>
 	<li>Confidentiality of your treatment and your treatment record, except the case of medical emergency or court order, or in specific cases where persons are at risk. Your treatment information may be released with a signed consent for clinical reasons and your protected health information may be used for treatment, payment, and healthcare operations according to our Notice of Privacy Practices;</li>
 	<li>Refuse services offered to you and be informed of any potential concerns. If services are refused and imminent danger is a potential concern, mandated reporting laws will require the agency to report the concerns to the appropriate persons;</li>
 	<li>Within specific limitations, to request a copy of treatment records in writing;</li>
 	<li>Request an interpreter;</li>
 	<li>Question any aspect of your treatment experience, and express a complaint or grievance by contacting our Clinical Director. Your grievance will be dealt with without retribution.</li>
</ul>
YOUR RESPONSIBILITIES:
<ul>
 	<li>Provide complete and accurate information about your current and past illnesses, symptoms, diagnoses and treatment, all medications and hospitalizations to help us in your treatment planning;</li>
 	<li>Provide current information about your address, contact number and insurance information and inform us immediately of any changes;</li>
 	<li>Participate in your treatment and to cooperate with your treatment plan;</li>
 	<li>Keep track of scheduled appointment dates and times and attend all scheduled treatment appointments on time;</li>
 	<li>Understand what medication you are taking and comply with all medication orders. The prescriber will provide you with information regarding any potential side effect and risks of medications prescribed by our facility;</li>
 	<li>Communicate to us what you need. If there is any component of your treatment that you do not understand, ask questions;</li>
 	<li>Comply with agency rules and regulations;</li>
 	<li>Make payments at time of service and comply with all financial agreements;</li>
 	<li>Cancel or reschedule appointments with at least 24 hours notice. Messages can be left after hours on the auto attendant either on your clinician’s voicemail box or extension 391;</li>
 	<li>Provide us with feedback on how to improve your care.</li>
</ul>
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