1. To be informed of these rights, as evidenced by the patient’s written acknowledgment,  or by  documentation by staff in the medical record, that the patient was offered a written copy of these rights and given a written or verbal explanation of these rights, in terms the patient could understand.  The North Hudson Community  Action Corporation Health Center shall have a means to notify a patients of any rules and regulations it has adopted governing patient conduct in the facility;

2. To be informed of services available at North Hudson Community Action Corporation Health Center, of the names and professional status of personnel providing and/or responsible for the patient’s care, and of fees and related charges, including the payment, fee, deposit, and refund policy of the facility and any charges for services not covered by sources of third-party payment or not covered by the facility’s basic rate;

3. To be informed it the North Hudson Community Action Corporation Health Center has authorized other health care and educational institutions to participate in the patient’s treatment.  The patient also shall have a right to know the identity and function of these institutions, and to refuse to allow their participation in the patient’s treatment;

4. To receive from the patient’s physician(s) or clinical practitioner(s), in terms that the patient understands an explanation of his or her complete medical/health condition or diagnosis, recommended treatment, treatment options, including the option of no treatment, risk(s) of treatment, and expected result(s).  If this information would be detrimental to the patient’s health, or if the patient is not capable of understanding the information, the explanation shall be provided to the patient’s next of kin or guardian.  This release of information to the next of kin or guardian, along with the reason for not informing the patient directly, shall be documented in the patient’s medical record;

5. To participate in the planning of the patient’s care and treatment, and to refuse medication and treatment.  Such refusal shall be documented in the patient’s medical record;

6. To be included in experimental research only when the patient gives informed, written consent to such participation, or when a guardian gives such consent for an incompetent patient in accordance with law, rule and regulation.  The patient may refuse to participate in experimental research, including the investigation of new drugs and medical devices;

7. To voice grievances or recommend changes in policies and services to North Hudson Community Action Corporation Health Center personnel, the government authority, and/or outside representatives of the patient’s choice either individually or as a group, and free from restraint, interference, coercion, discrimination, or reprisal;

8. To be free from mental and physical abuse, free from exploitation, and free from use of restraints unless they are authorized by a physician for a limited period of time to protect the patient or others from injury, drugs and other medications shall not be used for discipline of patients or for the convenience of North Hudson Community Action Corporation Health Center personnel;

9. To confidential treatment of information about the patient.  Information in the patient’s medical record shall not be released to anyone outside the North Hudson Community Action Corporation Health Center without the patient’s approval, unless another health care facility to which the patient was transferred requires the information, or unless the release of the information is required and permitted by law, a third party payment contract, or a peer review, or unless the information is needed by the New Jersey State Department of Health for statutorily authorized purposes.  The facility may release date about the patient for studies containing aggregated statistics when the patient’s identity is marked;

10. To be treated with courtesy, consideration, respect and recognition of the patient’s dignity, individuality, and right to privacy, including, but not limited to, auditory and visual privacy.  The patient’s privacy shall also be respected when North Hudson Community Action Corporation Health Center personnel are discussing the patient;

11.To not be required to perform work for North Hudson Community Action Corporation Health Center unless the work is part of the patient’s treatment and is performed voluntarily by the patient.  Such work shall be in accordance with local, State, and Federal laws and rules;

12. To exercise civil and religious liberties, including the right to independent personal decisions.  No religious beliefs or practices, or any attendance of religious services, shall be imposed upon any patient;

13. To not be discriminated against because of age, race, religion, sex, nationality, or ability to pay, or deprived of any constitutional, civil and/or legal rights solely because of receiving services from North Hudson Community Action Corporation Health Center; and

14. To be informed, assessed and treated for pain.

15. To be offered a chaperone during breast, genital and rectal exams. I have the right to refuse the chaperone and I am aware that this may result in the termination of the exam.