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BILL OF RIGHTS AND RESPONSIBILITIES
The patient has the right – To receive information about services covered under hospice
To receive information about scope of services hospice will provide as well as limitations
To have his or her property and person treated with respect
To choose his or her attending MD
To refuse care or treatment
To exercise his or her rights as a patient of the hospice
To voice grievances regarding treatment of care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice
To not be subjected to discrimination or reprisal for exercising his or her rights.
Hospice has the responsibility -
To inform and distribute written information to patient concerning its policy and procedure on advance directives
To maintain confidentiality of clinical records
To receive effective pain management and symptom control from the hospice for
conditions related to the terminal illness
_________________________________ ____________
PATIENT SIGNATURE DATE
_____________________________ _____________
PATIENT’S LEGAL REPRESENTATIVE DATE
SIGNATURE
______________________________ ____________
WITNESS SIGNATURE DATE
