Your Rights and Responsibilities

OUT-OF-NETWORK DISCLOSURE

IMPORTANT NOTICE REGARDING INSURANCE COVERAGE

This Ambulatory Surgery Center may be out-of-network with your insurance plan.

This means:

Your insurance may reimburse at a lower rate.
You may have a higher deductible and coinsurance.
You may be responsible for the difference between our billed charges and your insurance payment.

If your procedure is elective and scheduled in advance, you have the right to:

Contact your insurance carrier to verify benefits.
Request an estimate of charges.
Seek care at an in-network facility if available.

Chico is currently in-network with Aetna, Cigna, Imperial, Triwest/VA CCN.

PATIENT RIGHTS

Access equal medical treatment and accommodations without discrimination based on race, creed, sex, national origin, religion, or payment sources for care.
Obtain comprehensive information, to the extent available from the physician, concerning diagnosis, evaluation, treatment, procedures, and prognosis, including associated risks, side effects, and anticipated outcomes before the procedure.
Grant or refuse informed consent and actively participate in decisions regarding care, treatment, or services.
Exercise rights without facing discrimination or retaliation.
Express concerns about treatment or care that is provided or withheld.
Maintain personal privacy.
Obtain care within a safe environment and receive dignified treatment.
Remain protected from all forms of abuse, exploitation, or harassment.
Obtain necessary care to achieve or sustain maximum health status and, when needed, receive support in coping with end-of-life matters.
Obtain notification of rights before the surgical procedure through both verbal and written communication in a language and format that guarantees comprehension by the patient, patient’s representative, or patient’s surrogate.
Anticipate that caregiving personnel will demonstrate friendliness, consideration, respect, and appropriate qualifications through education and experience, while delivering services with the highest quality standards.
Obtain complete information regarding available services at the facility, after-hours care provisions, and associated service fees.
Participate actively in decisions concerning treatment intensity and scope. When the patient cannot participate in such decisions, a designated representative, surrogate, or other legally authorized person shall exercise the patient’s rights.
Make knowledgeable decisions about care.
Decline treatment within legal parameters and receive information about the medical consequences of such refusal. The patient assumes responsibility for actions including treatment refusal or non-compliance with physician or facility instructions.
Authorize or deny the release of medical records to individuals outside the facility, except as mandated by law or third-party payment agreements.
Receive notification of any human experimentation or research/educational projects impacting care or treatment and decline participation without compromising standard care.
Voice grievances, complaints, and suggestions at any time and have the organization review them.
Obtain access to and copies of medical records.
Receive information regarding the facility’s advance directives/living wills policy.
Obtain complete information before any transfer to another facility or organization and confirm the receiving facility has accepted the transfer.
Practice spiritual beliefs and cultural customs that don’t interfere with or harm the planned medical therapy.
Anticipate the facility’s compliance with Federal Civil Rights Laws ensuring interpretation services for individuals with limited English proficiency.
Undergo pain assessment and regular reassessment.
Receive education, along with families when appropriate, about their role in pain management.
Change providers when other qualified alternatives are available.
When a patient is deemed incompetent under applicable state health and safety laws by a court with proper jurisdiction, rights are exercised by the person appointed under state law to act on the patient’s behalf.
When a state court has not declared a patient incompetent, any legal representative designated by the patient according to state laws may exercise patient rights to the extent state law permits.

PATIENT RESPONSIBILITIES

Demonstrate respect and consideration toward other patients and personnel and assist in controlling noise, eating, and other disruptions.
Respect the property of others and the facility.
Communicate whether the planned treatment course is clearly understood and what is expected.
Honor appointments and notify the facility and physician when unable to attend for any reason.
Supply caregivers with the most precise and comprehensive information about current complaints, previous illnesses and hospitalizations, medications (including over-the-counter products and dietary supplements), allergies or sensitivities, unexpected condition changes, or any other health-related matters.
Adhere to the treatment plan established by the provider and actively participate in care.
Arrange for a responsible adult to provide transportation home from the facility and remain present for 24 hours, if the provider requires it.
Follow prescribed facility regulations during the stay and treatment, understanding that failure to comply may result in forfeiture of care at the facility.
Fulfill financial obligations to the facility promptly and accept personal financial responsibility for charges not covered by insurance.
Identify any patient safety concerns.
Ensure that the patient and accompanying individuals demonstrate respect toward all healthcare providers, staff, other patients, and visitors, and comply with the center’s policies.

ADVANCE DIRECTIVE NOTIFICATION

Every patient possesses the right to participate in healthcare decisions and establish Advance Directives or execute Powers of Attorney authorizing others to make decisions on their behalf based on expressed wishes when unable to make or communicate decisions. CSA honors and upholds these rights.

Our team commits to providing the highest quality care within a safe environment that centers on the patient. We honor your right to participate in care decisions and self-determination and will thoughtfully consider your requests. Following thorough consideration and review of applicable state regulations, facility leadership has established a policy to initiate resuscitative or other stabilizing interventions and arrange transfer to an acute care hospital for additional evaluation. Since the majority of procedures conducted at CSA carry minimal risk, the likelihood of requiring such measures is extremely low. At the acute care hospital, further treatment or withdrawal of initiated treatment measures will proceed according to your wishes, advance directive, or healthcare power of attorney.

You may choose to proceed with care at our facility or schedule the procedure at an alternative location that may not impose the same limitations. Having received complete information about our Statement of Limitations, you elect to proceed with your procedure at CSA.

Official State advance directive forms are available at our facility if you wish to complete one.

Should you disagree with this facility’s policy, we will gladly assist you in rescheduling your procedure.

PATIENT COMPLAINT OR GRIEVANCE

To report a complaint or grievance you can contact the facility Administrator by phone at CSA 530-487-8114 or by mail at: info@norcalpaindocs.com

Medicare beneficiaries may receive information regarding their options under Medicare and their rights and protections by visiting the website for the Office of the Medicare Beneficiary Ombudsman at:

https://www.cms.gov/center/special-topic/ombudsman/medicare-beneficiary-ombudsman-home
https://www.medicare.gov/claims-appeals/how-to-file-a-complaint-grievance
https://www.medicare.gov/basics/your-medicare-rights/get-help-with-your-rights-protections

No Surprises Act Information

No Surprises Act / Good Faith Estimate:

Uninsured or self-pay patients have the right to receive a Good Faith Estimate explaining the expected cost of medical services. You may request an estimate before scheduling or receiving services at Chico Surgical Affiliates. For more information, visit CMS No Surprises Act Information.

https://www.cms.gov/nosurprises

Language Assistance

Chico Surgical Affiliates provides free language assistance services, including interpreter services and translated materials, for patients whose primary language is not English. Please contact our office if you need language assistance prior to your appointment.

Non-Discrimination Notice

Chico Surgical Affiliates does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, sexual orientation, religion, or any other protected classification under applicable law. Language assistance and reasonable accommodations are available free of charge upon request.

Chico Surgical Affiliates complies with applicable Federal civil rights laws and California law and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, sexual orientation, religion, ancestry, medical condition, marital status, genetic information, or source of payment.

We provide:

Reasonable accommodations for individuals with disabilities

Appropriate auxiliary aids and services, including qualified interpreters when reasonably available

Language assistance services for individuals whose primary language is not English

These services are provided free of charge when necessary to ensure meaningful access to care and services.

If you need accommodations, language assistance, or believe that you have experienced discrimination, please contact:

Administrator

Chico Surgical Affiliates

615 W East Ave, Chico, CA 95926. Ph 530-487-8114

You may also file a civil rights complaint with:

California Department of Public Health https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/FileAComplaint.aspx
Center for Health Care Quality
California Department of Public Health Complaint Information
S. Department of Health & Human Services
Office for Civil Rights
HHS Office for Civil Rights Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaints may be filed electronically, by mail, or by phone.

At our clinic, our mission is to help you live a pain-free and active life. We provide personalized, compassionate care tailored to each patient’s unique needs.