Patient Rights

1. Considerate and respectful care, and to be made comfortable. You have the right to respect for your cultural, psychosocial, spiritual, and personal values, beliefs and preferences.

2. Have family (or other representative of your choosing) be involved in care, treatment, or services decisions to the extent permitted by you or your surrogate decision maker, in accordance with laws and regulations.

3. Know the name of the licensed health care practitioner acting within the scope of his or her professional licensure who has primary relationship for coordinating your care, and the names and professional relationships of physicians and nonphysicians who will see you.

4. Receive information about health status, diagnosis, prognosis course of treatment, prospects for recovery and outcomes (including unanticipated outcomes) in terms you can understand. Receive information in a manner tailored to your level of understanding, including provision of interpretive assistance or assistive devices. You have the right to effective communication and to participate in the development and implementation of your plan of care.

5. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or no treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. Receive assistance when requesting a change in physician if other qualified physicians are available.

6. Give or withhold informed consent to produce or use recordings, film, or other images for purposes other than care, and to request cessation of production of the recordings, films or other images at any time.

7. Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the facility even against the advice of members of the medical staff, to the extent permitted by law.

8. Be advised if the facility/licensed healthcare practitioner acting within the scope of his or her professional licensure proposes to engage in or perform human experimentation affecting your care or treatment. You have the right to refuse to participate in such research projects.

9. Appropriate assessment and management of pain, information about pain, pain relief measures and participation in pain management decisions.

10. Have an advance directive, such as a living will or durable power of attorney for healthcare, and be informed as to the center’s policy regarding advance directives/living will. Expect the center to provide the state’s official advance directive form if requested and where applicable.

11. Confidential treatment of all communications and records pertaining to your care at the facility. You will receive a separate “Notice of Privacy Practices” that explains your privacy rights in detail and how we may use and disclose your protected health information.

12. Access to and/or copies of your medical records within a reasonable time frame and the ability to request amendments to your medical records.

13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse. Respect of personal privacy.

14. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff.

15. Obtain information on disclosures of health information within a reasonable time frame. Examine and receive an explanation of the facilities bill regardless of the source of payment.

16. Exercise these rights without regard to sex, economic status, educational background, race, color, religion, ancestry, national origin, sexual orientation, gender identity/expression, disability, medical condition, marital status, age, registered domestic partner status, genetic information, citizenship, primary language, immigration status (except as required by federal law) or the source of payment of care.

17. Expect the center to disclose, when applicable, physician financial interests or ownership in the facility.

18. If a patient is adjudged incompetent under applicable State Laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under State Law to act on the patient’s behalf.

19. If a State court has not adjudged a patient incompetent, any legal representative or surrogate designated by the patient in accordance with State law may exercise the patient’s rights to the extent allowed by State law.

20. File a grievance. If you want to file a grievance with this facility, you may do so by writing or by calling: Patient Relations Officer OICPatientRelations@mednet.ucla.edu 213.742.1336 403 West Adams Boulevard, Los Angeles CA 90007 The grievance committee will review each grievance and provide you with a written response within 10 business days. The written response will contain the name of a person to contact at the facility, the steps taken to investigate the grievance, the results of the grievance process. Concerns regarding quality of care or premature discharge will also be referred to the appropriate Quality Assurance and Performance Improvement (QAPI) committee.

21. You may also contact the following entities to express any concerns, complaints or grievances you may have:Medical Board of California Central Complaint Unit 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815 Toll-Free: 800.633.2322 Phone: 916.263.2382 Fax: 916.263.2435 www.mbc.ca.gov/Breeze/Complaints.aspx Medicare: Office of Medicare Ombudsman https://www.medicare.gov/claims-appeals

Patient Responsibilities

1. Being considerate of other patients and personnel and for assisting in the control of noise, smoking and other distractions. Respecting the property of others and the center.

2. Identifying any patient safety concerns.

3. Providing a responsible adult to transport you home from the center and remain with you for 24 hours if required by your provider.

4. Reporting whether you clearly understand the planned course of treatment and what is expected of you and asking questions when you do not understand your care, treatment, or service or what you are expected to do.

5. Keeping appointments and, when unable to do so for any reason, notifying the center and physician.

6. Providing caregivers with the most accurate and complete information regarding present complaints, past illnesses and hospitalizations, medications, unexpected changes in your condition or any other patient health matters.

7. Promptly fulfilling your financial obligations to the center, including charges not covered by insurance.

8. Payment to center for copies of the medical records you may request.

9. Informing your providers about any living will, medical power of attorney, or other advance directive that could affect your care.

Urgent Care

• Pediatric Orthopaedic Urgent Care Center Registration Forms – English

• Pediatric Orthopaedic Urgent Care Center Registration Forms – Spanish

Cerebral Palsy

• Patient Intake – Initial Visit

• Patient Health Assessment

• Pediatric Health Assessment – Age 2-10 years

• Adolescent Health Assessment – Patient-Reported

• Adolescent Health Assessment – Parent Reported

Scoliosis

• Scoliosis Patient Questionnaire