(636) 203-9700

1055 Bowles Ave, Suite 100
Fenton, MO 63026

Phone: (636) 203-9700
Fax: (636) 203-9779

1055 Bowles Ave, Suite 100
Fenton, MO 63026

Your Rights and Responsibilities

This page seeks to provide you with...

  • Your Rights and Responsibilities relating to your surgery
  • Instructions for how to file a grievance, if desired
  • Information concerning physician ownership of our center
  • The Center’s policy with respect to advance directives

YOUR RIGHTS

You have the right to:

  • Receive service(s) without regard to age; race; color; sex; sexual orientation; marital status; disability; veteran’s status; national origin; cultural, economic, educational, or religious background; or the source of payment for care, without being subjected to discrimination or reprisal.
  • Be treated with consideration, respect, and dignity, including privacy in treatment in a safe environment.
  • Be informed of the services available at the facility.
  • Be informed of the provisions for off-hour emergency coverage.
  • Knowledge of the name of the physician that has primary responsibility for coordinating your care and the names and professional relationships of other physicians and non-physicians who will participate in your care.
  • Knowledge of your right to change primary or specialty physicians.
  • Receive information from your physician about your illness, course of treatment, and prospects for recovery in terms that you can understand.
  • Receive as much information about the proposed treatment or procedure as you may need in order 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 the treatment, alternate course of treatment or non-treatment, the risks involved in each, and the name of the person who will carry out the procedure or treatment.
  • Participate actively in decisions regarding your medical treatment including the right to refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of your actions.
  • Have pain assessed and managed as part of the treatment process, and have your reports of pain believed and responded to quickly.
  • Full consideration of privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discretely. You have the right to be advised as to the reason for the presence of any individual.
  • Confidential treatment of all communications and records pertaining to care. Written permission shall be obtained before medical records can be made available to anyone not directly concerned with your care.
  • To be given the opportunity to approve or refuse their release, except when release is required by law, of your record.
  • Reasonable responses to any reasonable requests made for service.
  • Leave the facility even against the advice of physicians.
  • Be informed regarding patient billing practices, charges for services, eligibility for third-party reimbursements, and, when applicable, the availability of free or reduced-cost care.
  • Receive a copy of account statement upon request.
  • Make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment or participate in any experimental research.
  • Know that the health care providers have their credentials and privileges verified.
  • Receive verbal and written notice of your rights in advance of the date of the procedure.
  • Receive written information of your physician’s financial interest in the ASC.
  • To be provided with information concerning the ASC’s policies on advance directives, including a description of applicable state health and safety laws and, if requested, official state advance directive forms.
  • To exercise your rights.
  • Be fully informed about a treatment or procedure and the expected outcome before it is performed.
  • To have your rights exercised by the person appointed under state law to act on your behalf if you are adjudged incompetent under applicable state health and safety laws by a court of proper jurisdiction.
  • If a state court has not adjudged you incompetent, any legal representative designated by you in accordance with state law may exercise your rights to the extent allowed by state law.
  • To be free of all forms of abuse of harassment.

You have the right to submit an ADVANCE DIRECTIVE.

All patients have the right to make advance directives or to execute powers of attorney that authorize others to make decisions on the patient’s behalf based on their expressed wishes when unable to make or communicate decisions. This Center respects and uphold those rights.

However, unlike an acute care hospital setting, most procedures performed in this facility are minimal risk. Of course, no surgery is without risk, and you will discuss procedure specifics (risks, recovery, after-care) with your physician. Therefore, it is our policy, regardless of the contents of any advance directive or instructions from a health care surrogate, attorney-in-fact, or holder of a healthcare provider, that if an adverse event occurs during your treatment at the Center we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. At the acute care hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, advance directive, or health care power of attorney.

For further clarification, please contact the Center directly at (636) 203-9700 and request to speak with the Center’s Director.

You have the right to access the Advance Health Care Directive described in Caring Connections, a national program of the National Hospice and Palliative Care Organization (NHPCO). This program, aimed at improving care at the end of life, includes:

  • Instructions for completing the Missouri Advance Directive for Healthcare
  • Learning options for end-of-life services and care
  • How to make sure that your wishes are honored
  • How to tell your family, friends, and healthcare providers about your decision
  • How to participate in personal and community efforts to improve end-of-life care
  • A copy of the Missouri Durable Power of Attorney for Healthcare

This information is available on the Caring Connections website:

http://www.caringinfo.org/files/public/ad/Missouri.pdf

Upon request, you, your representative, or your surrogate, can obtain a copy of your state’s Advance Directive form at the Center.

YOUR RESPONSIBILITIES

You are responsible for:

  • Providing accurate and complete information concerning your present condition or complaints, past medical history, any medications, including over-the-counter products and dietary supplements, and any allergies or sensitivities and other matters about your health.
  • Making it known whether you clearly comprehend the course of your medical treatment and what is expected.
  • Following the treatment plan established by the physician, including the instructions of nurses and other health professionals as they carry out the physician’s orders.
  • Keeping appointments and for notifying the facility or physician when you are unable to do so.
  • Being in charge of your actions should you refuse treatment or not follow the physician’s orders.
  • Ensure that the financial obligations of care are fulfilled as promptly as possible.
  • Follow facility policies and procedures.
  • Providing a responsible adult to transport you from the facility and remain with you for 24 hours, if required by the provider.
  • Inform the provider and facility about any living will, medical power of attorney, or other directive.
  • Be considerate of the rights of other patients and facility personnel.
  • Be respectful of personal property and that of other persons in the facility.

You should respect the rights of other patients and the staff of this surgery center by:

  • Helping us to control noise
  • Not smoking
  • Limiting the number of visitors

This surgery center has the right to refuse care to or dismiss patients who are disruptive, uncooperative, rude, or physically threatening to other patients or our staff.

If your driver is disruptive, uncooperative, rude, or physically threatening, this surgery center has the right to refuse care to you or dismiss you from care. This includes drivers who are unable to provide safe transportation for any reason, including drug or alcohol intoxication.

Voice Your Concerns or Suggestions

Without fear of reprisal, voice grievances regarding treatment or care, changes in policy and service, or other suggestions to…

The Center

Attn: Director

SSM St. Clare Surgical Center

1055 Bowles Ave, Suite 100

Fenton, MO 63026

(636) 203-9700

The State:

Missouri Department of Public Health is the agency responsible for ambulatory surgical centers’ complaint investigation.

Complaints may be filed with the Bureau of Health Services Regulation:

By mail: PO Box 570, Jefferson City, MO 65102-0570

By phone: (573) 751-6303

By fax: (573) 526-3621

By email: complaint@health.mo.gov

A complainant may provide his/her name, address, and phone number to the Department. All complaints are confidential.

Medicare:

Office of the Medicare Ombudsman:

http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

or 1-800-MEDICARE.

Financial Responsibilities

As a patient of the Center, I understand that any co-pays, co-insurance, and/or deductibles are due prior to having my procedure. I understand that the following provider fees are NOT INCLUDED in the surgery center fee and will be billed separately:

  • Physician (surgeon) fee
  • Anesthesiology fee
  • Durable medical equipment (DME) fee, if applicable
  • Pathology fee, if applicable
  • Laboratory services fee, if applicable

For any questions or concerns, please call (636) 203-9700.

Ownership Disclosure

The owners of the Center are:

  • M. Boedefeld
  • C. Shelton
  • A Levy
  • L Boveri
  • A. Eichholz
  • S. Boveri
  • B. Davidson
  • R. Olk
  • E. Peralta
  • S. Rose
  • R. Mirkin
  • S. Bailey
  • R. Brandsted
  • F. Pugliano
  • St. Louis ENT, LLC
  • M. Mastromichalis
  • FPP, Inc. (SSM Health)

All directly have financial interests and ownership in the Center.

You have the right to choose your provider and where your procedure is performed. For any questions or concerns, please feel free to contact your physician.