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Required Patient Notices

Prior to your day of surgery, you must review three patient notices:

1. Ownership Disclosure, Advance Directives and Grievances
2. Patient Rights and Responsibilities

Federal regulations require that you review these notices before your procedure.

Download and Review Patient Notices

Ownership Disclosure, Advance Directives and Grievances

Patient Rights and Responsibilities

Other Patient Notices

We also offer the following notices for your review

Patient Privacy

Patient Experience Survey

NOTICES

Ownership Disclosure/Patient Grievances/Advance Directives

What we are:

Pacific Gastroenterology Endoscopy Center an outpatient ambulatory endoscopy center licensed in the State of California.

Who we are:

Pacific Gastroenterology Endoscopy Center is owned by Om P. Chaurasia, MD. The center was developed to provide a safe and comfortable medical facility that would provide efficient and effective services to patients.

Why we opened:

Outpatient care has been proven to increase patient comfort through personalized care while delivering quality services.

Your rights as a patient:

You have the right to choose the provider and the facility for your health care services. You will not be treated differently by your physician if you obtain health care services at another facility.

Patient Grievances:

If patients have complaints or concerns in regard to your care at Pacific Gastroenterology Endoscopy Center, they are encouraged to fill out a grievance form, which is available upon request at the front desk. Contact numbers are available below.

Advance Directives:

Even if you have an advance directive or living will, the Center will still transfer you to the closest hospital which will make decisions about following any advance directive or living will. You have a right to have your living will present in our medical record at the Center and to be informed of the Center's policy prior to the date of admission. State information and forms to prepare an advance directive, if you decide to have one, can be found at the following web site: www.dhcs.ca.org

Consumer Complaints can me made at any of these:

The following investors have a financial interest in the Pacific Gastroenterology Endoscopy Center: Om P. Chaurasia, MD

PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES

The staff of this health care facility recognizes you have rights while a patient receiving medical care. In return, there are responsibilities for certain behavior on your part as the patient. These rights and responsibilities include:

The patient has the right to:

1. Treatment without regard to sex, or cultural, economic, educational, or religious background or the source of payment for his care.
   
   
2. Considerate and respectful care.
   
   
3. The knowledge of the name of the physician who has primary responsibility for coordinating his care and the names and professional relationships of other physicians who will see him and the credentials of health care professionals involved in his care.
   
   
4. Receive information from his physician about his illness, his course of treatment, and his prospects for recovery in terms he can understand.  When it is medically inadvisable to give such information to a patient, the information is provided to a person designated by the patient or to a legally authorized person.
   
   
5. Receive the necessary information about any proposed treatment or procedure to give informed consent or to refuse this course of treatment.  Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who would carry out the treatment or procedure.
   
   
6. Participate actively in decisions regarding his medical care.  To the extent permitted by law, this includes the right to refuse treatment.
   
   
7. Full consideration of privacy concerning his medical care program.  Case discussion, consultation, examination, and treatment are confidential and shall be conducted discreetly.  The patient has the right to be advised as to the reason for the presence of any individual.
   
   
8. Confidential treatment of all communications and records pertaining to his care.  His written permission shall be obtained before his medical records are made available to anyone not concerned with his care.
   
   
9. Reasonable responses to any reasonable request he makes for services.
   
   
10. Reasonable continuity of care and to know in advance the time and location of appointments as well as the physician providing the care.
    
    
11. Be advised if physician proposes to engage in or perform human experimentation affecting his care or treatment.  The patient has the right to refuse to participate in such research projects.
    
    
12. Be informed by his physician or designee of his continuing health care requirements.
    
    
13. Examine and receive an explanation of his bill regardless of source of payment.
    
    
14. Have all patient's rights explained to the person who has legal responsibility to make decisions regarding medical care on behalf of the patient.
    
    
15. Express any grievances or suggestions verbally or in writing to the Pacific Gastroenterology Endoscopy Center Management at (949) 365-8836 and/or California Department of Public Health at (949) 456-0630 or Office of the Medicare Beneficiary Ombudsman at 800-MEDICARE (800-633-4227) or online at www.cms.hhs.gov/center/ombudsman.asp

Patient Responsibilities

1. Good communication is essential to a successful physician-patient relationship.  To the extent possible, patients have a responsibility to be truthful and to express their concerns clearly to their physicians.
   
   
2. Patients have a responsibility to provide a complete medical history, to the extent possible, including information about past illnesses, medications, hospitalizations, family history of illness, and other matters relating to present health.
   
   
3. Patients have a responsibility to request information or clarification about their health status or treatment when they do not fully understand what has been described.
   
   
4. Once patients and physicians agree upon the goals of therapy, patients have a responsibility to cooperate with the treatment plan.  Compliance with physician instructions is often essential to public and individual safety.  Patients also have a responsibility to disclose whether previously agreed upon treatments are being followed and to indicate when they would like to reconsider the treatment plan.
   
   
5. Patients generally have a responsibility to meet their financial obligations with regard to medical care or to discuss financial hardships with their physicians. Patients should discuss end-of-life decisions with their physicians and make their wishes known.  Such a discussion might also include writing an advanced directive.
   
   
6. Patients should also have an active interest in the effects of their conduct on others and refrain from behavior that unreasonably places the health of others at risk.  Patients should inquire as to the means and likelihood of infectious disease transmission and act upon that information which can best prevent further transmission.
   
   
7. Patients should also have an active interest in the effects of their conduct on others and refrain from behavior that unreasonably places the health of others at risk. Patients should inquire as to the means and likelihood of infectious disease transmission and act upon that information which can best prevent further transmission.

PATIENT PRIVACY

This notice describes how we may use and disclose your protected health information to carry out treatment, payment or healthcare operations and for other purposes permitted or required by law. Please review it carefully. We must follow the privacy practices described in this notice while it is in effect. We reserve the right to change the terms of this notice and to make a new notice available to anyone. You may request a copy of our current notice at any time. This privacy notice also describes your rights to access and control your protected health information, which is health information created or received by your healthcare provider.

Uses and disclosures of protected health information:

We will use and disclose health information to provide treatment, obtain payment and conduct healthcare operations.

1. Treatment: To provide and coordinate your healthcare. For example, we may disclose protected health information to physicians or other healthcare professionals who may be treating you or consulting with us. Examples include your physicians, anesthesia provider or pharmacist.
   
   
2. Payment: To obtain payment for the services. This may include contact with your insurance company to get the bill paid and to determine benefits of your health plan. We may also disclose information to another provider involved in your care so the provider can get paid. For example, we may give information to anesthesia providers so they can contact your insurer about payment for their service.
   
   
3. Operations: To perform our own healthcare activities such as quality assessment and improvement, licensing or credentialing and general business administration.
   
   
4. Other Uses and Disclosure: To remind you of appointments or to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, or to notify family or others involved in your care concerning your location or condition. You may object to these disclosures. If you do not or cannot object, we will use our professional judgment to make reasonable assumptions about to whom we can make disclosures.
   
   
5. Other Uses and Disclosures Permitted: To comply with laws and regulations.
1. When legally required by any federal, state of local law.
2. When there are risks to public health, such as:
   • To prevent, control or report disease, injury or disability as required or permitted by law.
   • To report vital events, such as birth or death as required by law.
   • To conduct public health surveillance, investigations and interventions as required by law.
   • To collect or report adverse events and product defects, track Food and Drug Administration (FDA) regulated products, enable product recalls, repairs or replacements and review.
   • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.
   • To report to employer information about an individual who is a member of the workforce as legally permitted or required.
3. To report suspected abuse, neglect or domestic violence as required by law.
   
   
4. To conduct health oversight activities such as audits; civil, administrative or criminal investigations, proceedings or actions; inspections; licensing or disciplinary actions; or other activities necessary for appropriate oversight as required or authorized by law.
   
   
5. In connection with judicial and administrative proceedings such as in the course of any judicial or administrative proceeding.
   
   
6. For law enforcement purposes. Examples are:
   • As required by law for reporting of certain types of wounds or other physical injuries.
   • Upon court order, court-ordered warrant, subpoena, summons or similar process.
   • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
   • Under certain limited circumstances, when you are the victim of a crime.
   • To law enforcement if there is concern that your health condition was the result of criminal conduct.
   • In an emergency to report a crime.
     
     
7. For organ donation or to coroners or funeral directors such as for organ, eye or tissue donations; identification purposes; performing other duties authorized by law.
   
   
8. For research purposes when the use of disclosure for research has been approved by an institutional review board that has reviewed the research proposal and research protocols to address the privacy of your protected health information.
   
   
9. In the event of a serious threat to health or safety and consistent with applicable law and ethical standards of conduct if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
   
   
10. For specified government functions relating to military and veteran activities, national security, protective services, medical suitability determinations, correctional institutions and law enforcement situations.

Patient Rights

Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action based upon the authorization. At the end of the Privacy Notice, there is information about how to contact the Privacy Officer to request information, copies, express concerns, complain or authorize additional uses and disclosure of your health information.

You have the right to:

1. See and copy your medical records and other records used to make treatment and payment decisions about you. There are some limitations, based upon federal law. You must submit a written request. We may charge you a fee for copying, mailing or incurring other costs in complying with your request. We may deny your request to see or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger life or safety of you or another person. You have the right to request a review of this action.
   
   
2. Request a restriction on uses and disclosures of your protected health information. Our office is not required to agree to a restriction and we will notify you if we deny your request. If the center does agree to the requested restriction, we will abide by this agreement unless use of disclosure of the information becomes essential to provide emergency treatment.
   
   
3. The right to request to receive confidential communications by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will not require you to provide an explanation for your request. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.
   
   
4. The right to request we amend your protected health information. A request for an amendment must be in writing and it must explain why the information should be amended. Under certain circumstances, we may deny your request.
   
   
5. The right to receive an accounting of disclosures. You have the right to request an accounting of how we or our business associates disclosed your protected health information for purposes other than treatment, payment or healthcare operations. We are not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures to friends or family members involved in your care, or certain other disclosures we are permitted to make without your disclosures that occurred prior to April 14, 2003 or for periods of time in excess of six years. The first accounting you request during any 12-month period will be without charge. Additional accounting requests may be subject to a reasonable fee.
   
   
6. The right to obtain a paper copy of this notice at any time.

Complaints

You have the right to express complaints to the Endoscopy center if you believe that your privacy rights have been violated. We encourage you to express any concerns you have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. You may complain to the Endoscopy center's Privacy Officer in person, by phone or in writing. You also have the right to express complaints to the Secretary of the U.S. Department of Health and Human Services

Contact Person

To make requests, learn more, file a complaint

For more information about Health Insurance Portability and Accountability Act (HIPAA) and Health information privacy, you may visit the website of U.S. Department of Health and Human Services at www.hhs.gov

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PATIENT EXPERIENCE SURVEY

We have tried to make your experience at Pacific Gastroenterology Endoscopy Center as comfortable and pleasant as possible. Please let us know how well we are doing by taking this short survey and returning it to us. We greatly appreciate your feedback. Thank you.