As a patient, you have the right to be informed of these rights, in writing, prior to the initiation of care and the right to exercise such rights. As a patient you have the right to: 1. Competent, concerned, individualized care without regard to race, creed, color, age, sex, national origins, religion, sexual preference or disability. 2. Be treated with dignity, consideration, and respect, including respect for your privacy, your property, your safety/security and your personal cultural and ethnic preferences. You have the right to complain of disrespect for your property. 3. Expect Leaf Medical to maintain a written care plan, and include your participation, as able, in all decisions affecting your care and treatment. Be advised in advance of any changes in your plan of care. 4. Privacy and confidentiality of all information, including records pertaining to your treatment, except otherwise provided by law or third-party payment. 5. Know the names and functions of those people responsible for coordinating, rendering and supervising your health care, including the identity of other health care providers with which Leaf Medical has contractual relationships, and to expect that staff members will listen to voiced concerns and/or complaints. Be informed of all services Leaf Medical will provide, when and how such services will be provided. 6. Be fully informed of your diagnosis, prognosis and treatment, including alternatives to care and risks involved, with explanation by staff that is knowledgeable of your condition. Information will be presented in a form that you can understand. 7. Refuse treatment after being fully informed and understanding the consequences of such actions, without fear of discrimination or reprisal. 8. Receive information regarding Leaf Medical’s policies and procedures, including the discontinuation of service, and to be informed of continuing health care needs following transfer or discharge and to be involved in the plan for the provision of such care. 9. Have your complaints heard, reviewed, and if possible, resolved and recommended changes in policies and services to Leaf Medical staff, the governing authority and the New York State Department of Health (212-417-5888) without fear of reprisal, coercion, interference, discrimination, or unreasonable interruption in service. To file a grievance or to receive information in writing on how to file a grievance, submit complaints about the care and services provided or not provided or concerning lack of respect and lack of respect of property, write or call the administrator. 10. View your clinical record in Leaf Medical or receive a copy of it. 11. Examine, question and receive a full explanation of any bill regardless of source of payment. 12. All rights and responsibilities specified as they pertain to a patient lacking capacity to exercise these rights; the rights will be exercised by an individual, guardian or entity legally authorized to represent the patient. 13. The governing authority shall make all personnel providing patient care service on behalf of Leaf Medical aware of the your rights and the responsibility of personnel to protect and promote your rights. 14. Be given a statement of services available by Leaf Medical and related charges, including the actual dollar amount to be borne to you; be advised prior to initiation of care of the extent to which payment for Leaf Medical services may be expected from any third party payer and the extent from which payment may be required from the patient, to be advised of any changes in such as soon as possible but no later than 30 calendar days from the date Leaf Medical was aware of the change. This information shall be provided in writing and orally. 15. Be given information on patient self-determination, Advance Directives, health care proxy, living will and DNR. Existence or lack of Advance Directives does not hamper your access to care or services. 16. Be given information in a language or form you can reasonably understand. 17. Information about the ownership of Leaf Medical. 18. Not to receive experimental treatment or participate in research unless you have given documented voluntary informed consent. 19. Participate in ethical issues and the resolution of conflicts arising in your care. 20. Be referred to other organizations, services, or individuals and be informed of any financial benefit to the referring organization. 21. Appropriate assessment of your reports of pain by concerned, qualified staff, as well as information about pain, pain relief measures and the effective management of your pain.


Leaf Medical expects that the patient will: 1. Be seen by the doctor if a change in your health status occurs. 2. Share complete and accurate health information with Leaf Medical staff, including present complaints, pain, past illnesses, hospitalizations, medications and your pain management regimen; if applicable. 3. Inform staff of any changes in your health status and make it known if you do not understand or cannot follow instructions. Asks questions about your care and/or service. 4. Be responsible for the following treatment plan recommended by Leaf Medical and advise Leaf Medical of any problems or dissatisfaction with health services. 5. Cooperate with and be respectful of Leaf Medical’s personal property and not discriminate against staff of race, creed, color, sex, age, sexual orientation, religion, national origin or handicap. 6. Notify Leaf Medical if you receive services from any other facility and/or if you use any medical equipment, which you no longer use. 8. Be responsible for your actions if you refuse treatment or do not follow Leaf Medical’s instructions. 9. Be responsible for assuring that the financial obligations of your health care are fulfilled as promptly as possible. 10. Notify Leaf Medical of the existence of and any changes made to Advance Directives. 11. Follow Leaf Medical’s policies and procedures concerning patient care and conduct.


As a patient, I consent to the release of information by any physician, hospital, extended care facility or home health agency of which I have been a patient and authorize such physician, hospital, extended care facility or home care agency to disclose all or part of my medical record, including information on infectious diseases, to a representative of Leaf Medical, as it applies to my health care. As a patient, I consent to the release of information (verbal, electronic, facsimile or photographic copies) and/or disclosure of all or any part of my clinical record by Leaf Medical to be reviewed by my private insurance Leaf Medical for use in determining my health care benefits. As a patient, I consent to the release of information (verbal, electronic, facsimile or photographic copies) and/or disclosure of all or any part of my clinical record by Leaf Medical to any physician hospital, or other entity of which I am or have been a patient. As a patient, I consent to the review of my clinical record by the regulatory/accrediting body surveyors for purposes of audit and evaluation.

Uses of PHI that require your authorization

Other than for the purposes described above, we must obtain your written authorization to use or disclose certain PHI deemed “Highly Confidential.” For certain kinds of PHI, Federal and state law may require enhanced privacy protection. These would include PHI that is: • Maintained in psychotherapy notes. • About alcohol and drug abuse prevention, treatment and referral. • About HIV/AIDS testing, diagnosis or treatment. • About venereal and/or communicable disease(s). • About genetic testing. We can only disclose this type of specially protected PHI with your prior written authorization except when specifically permitted or required by law. Any other uses and disclosures not described in this Notice will only be made with your prior written authorization.


As a patient, I acknowledge the receipt of the PATIENT’S BILL OF RIGHTS, HIPAA information and requirements and the STATE DEPARTMENT OF HEALTH telephone number, and I understand these rights and responsibilities. As a patient, I acknowledge that no guarantees or assurances have been made to me concerning the health care service that will be provided by Leaf Medical. I consent to abide by Leaf Medical’s specific policies and procedures relating to my health care which have been reviewed with me and which include provisions for termination of services at my request, and /or Leaf Medical’s request. As a patient, I acknowledge receipt of information pertaining to Advance Directives: DO NOT RESUSCITATE ORDER, LIVING WILL, and HEALTH CARE PROXY. As a patient, I understand that Leaf Medical DOES NOT require its staff members to be CPR-certified. If an individual staff member is CPR-certified, Leaf Medical will provide resuscitation masks, as per OSHA requirement. If a staff member is not CPR-certified, 911 (or emergency services) would be called immediately in the event of a cardiac arrest, as per the patient’s advance directive wishes. I acknowledge that I have received and reviewed Leaf Medical’s grievance procedure which includes general and discrimination grievances.

I acknowledge that my consent is voluntary and that my refusal to participate at this time would in no way affect my benefits under any other Leaf Medical or program. I acknowledge and consent to the contents of this statement.