Patient Rights and Responsibilities

Main Campus
2727 West Holcombe Blvd.
3rd Floor Suite 100
Houston, Texas 77025
713-442-0000

North Houston Campus
15655 Cypress Woods Medical Dr.
Houston, Texas 77014
713-442-1700

Memorial Villages
1001 Campbell Rd
Houston, TX 77055
713-442-6900

Patient Rights

Kelsey-Seybold Clinic Ambulatory Surgical Centers provides access to treatment or accommodations that are available or medically indicated without regard to race, creed, sex, nationality, gender, disability, age, or sources of required payment.

You are entitled to safe, considerate, respectful and dignified care at all times.

This includes your right to:

Receive care in a safe setting, free from abuse or harassment.
Receive appropriate assessment and safe and effective pain management.
Receive respectful consideration and care with recognition of personal values and belief systems.
Wear appropriate personal clothing or religious, cultural or other symbolic items that do not interfere with recommended diagnostic procedures or treatment.

You are entitled to personal and informational privacy as required by law.

This includes your right to:

Refuse to talk with or see anyone not officially connected with the Clinic, including visitors or persons officially connected with the Clinic but not directly involved with your care.
Request a person of your own gender present during physical examination, treatment, or procedure performed by a health professional of the opposite gender.
Refuse to remain disrobed any longer than is required for accomplishing the medical purpose for which you were asked to disrobe.
Be interviewed and examined in surroundings designed to assure reasonable visual and auditory privacy.
Expect that any discussion or consultation involving your case should be conducted discreetly and that individuals not directly involved in your care should not be present without your permission.
Know the identity, credentials, professional status, role and financial and/or business relationship of all those involved in your care.
- NOTE: The Ambulatory Surgical Centers are owned by Kelsey-Seybold Medical Group, PLLC, and some of the physicians and surgeons practicing in the ASC are members of the Medical Group.

You are entitled to confidentiality regarding disclosures and records.

This includes your right to:

Have your medical record read by individuals directly involved in your treatment, in the monitoring of its quality, with your written authorization, or by those who have legal custody, or other authorized individuals.
Expect communications and records pertaining to your care, including the source of payment for treatment, to be treated as confidential.

You are entitled to be involved in your care and to participate in decisions involving your care, except when such participation is contraindicated for medical reasons.

(When it is not medically advisable to give such information to the patient, the information should be available to a legally authorized individual.)

This includes your right to:

Obtain complete and current information concerning your diagnosis, to the degree known, evaluation, treatment, and prognosis.
Know who is responsible for coordinating your care and authorizing and performing your procedures or treatment.
Be informed with a clear, concise explanation of your condition and of the appropriate treatment options, including their risks and benefits, alternative treatment options, the consequences of no treatment, and the results of medical care provided – including any unanticipated adverse outcomes.
Consult with another physician or specialist in order to obtain a second opinion regarding your condition or treatment at your own expense or consistent with your health plan coverage.
Refuse treatment to the extent permitted by law. When refusal of treatment prevents the provision of appropriate care in accordance with professional standards, the relationship may be terminated upon reasonable notice.
Refuse to undergo involuntary treatment or be subjected to research or experimental procedures without your written consent, or that of your legal representative

You are entitled to information regarding Transfers, Continuity of Care, Provisions for after-hours Care and Emergency Care.

This includes your right to:

Receive a complete explanation regarding the necessity for the transfer and of the alternatives to such transfer.
Be informed by the practitioner responsible for your care, or their delegate, of any continuing health care requirements following discharge from the clinic.
Expect plans for reasonable continuity of care after discharge so that continuing health care needs may be met.
Be informed of provisions for after-hours care such as: Physician Call Rotation, After-Hours Nurse Triage, Answering Service, Referrals to an Emergency Department, and Weekend Clinics.

You are entitled to receive and examine an explanation of all bills regardless of the source of payment.

This includes your right to:

Request a cost estimate of a proposed medical service. If you are an uninsured, patient you may request information about discounts for medical services.
Request and receive an itemized and detailed explanation of your total bill for services rendered in the Ambulatory Surgical Centers.
Receive timely notice prior to termination of your eligibility for reimbursement by a third-party payer for the cost of your care.

You are entitled to have an advance directive, as required by state or federal law and regulations.

This includes your right to:

Obtain information regarding an advance directive.
Formulate advance directives, to appoint in writing a durable power of health care attorney, or by operation of law to have a surrogate decision-maker to make health care decisions on your behalf to the extent permitted by law.
Have your advance directive (if you have one) included in your medical record.
Have your advance directive followed to the extent that is medically appropriate and lawful.
- NOTE: Because we provide surgery and procedures that are considered to be elective, our policy states that it is medically appropriate to initiate resuscitative or other stabilizing measures and transfer you to an acute-care hospital for further evaluation, if needed. At the acute-care hospital, further treatments or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive, or Healthcare Power of Attorney. If you do not agree with the organization’s policy on Advance Directives, we will assist you with rescheduling your procedure.

You are entitled to effective communication in a language and manner that you understand.

This includes your right to:

Have access to an interpreter if you are not fluent in English.
Kelsey-Seybold Clinic may be able to assist with the arrangements to provide, as a courtesy, non-English speaking patients with physicians and/or staff that speak your language. (If this is not possible, Kelsey-SeyboldClinic may refer non-English speaking patients to Masterword Services, which provides medical interpreters in their language. Non-English speaking patients may elect to obtain a preferred discounted rate for this service by calling 281-589-0810 in advance. The fee may be authorized for payment at Clinic expense in urgent situations at the discretion of the Medical Director, Section Chief, Managing Physician and/or designee).
Have necessary access for auxiliary aids and assistive animals if you have an impairment which requires use of these. In accordance with the Americans with Disabilities Act (ADA), Kelsey-Seybold Clinic should provide, at no cost, a sign language interpreter for hearing impaired individuals upon a request in advance of a procedure.

You are entitled to information about the rules and regulations of the Kelsey-Seybold Clinic Ambulatory Care Centers that are applicable to patient care and conduct.

You are entitled to information about the clinic mechanisms for the initiation, review, and resolution of patient complaints.

This includes your right to:

Be informed of procedures for expressing suggestions, complaints, and grievances, including those required by state and federal laws.
Express dissatisfaction regarding the quality of care without being subjected to discrimination, reprisal or jeopardizing future care.

Grievances can be voiced or filed with the following:

ASC Director Kelsey-Seybold Clinic
2727 W. Holcombe Blvd.
Houston, TX 77025
713-442-0000

Paula Moore, Admin Asst. IV
PQCU-MC 1979
Texas Dept. of State Health Services
P.O. Box 149347
Austin, TX 78714-9347
(p) 1-888-963-7111 (f) 512-834-6653

Office of Medicare Beneficiary Ombudsman
www.medicare.gov
1-800-Medicare (1-800-633-4227)

Be informed of notices concerning complaints about physicians, as well as other licensees and registrants of the Texas State Board of Medical Examiners, including physician assistants, acupuncturists, and surgical assistants. This information should be displayed in both English and Spanish.

You are encouraged to promote your own safety by becoming an active, involved and informed member of your health care team.

This includes your right to:

Ask questions if you are concerned about your health or safety. Verify your site/side of the body that will be operated on prior to the procedure.
Remind staff to check your ID before medications are given, blood samples are obtained or prior to an invasive procedure.
Remind the care-givers to wash their hands prior to giving care.
Be informed about which medications you are taking and why you are taking them.
Look for an identification badge to be worn on all Kelsey-Seybold Clinic Ambulatory Surgical Centers employees.

Patient Responsibilities

Provide complete and accurate information to the best of your ability about your health, any medications, including over-the-counter products and dietary or herbal supplements and any allergies or sensitivities.