Patient Rights and Responsibilities

All Patients Have the Right To:

• Ask questions
• Accessible health care
• Respect and dignity
• Information regarding status, care
• Consent of treatment
• Participation in plan of care
• Make informed decisions regarding care
• Formulate advance directives
• Management of pain
• Request of refusal of treatment
• Personal privacy
• Confidentiality of clinical records
• Protected health information
• Access to clinical records
• Identity of care givers
• Personal safety
• Freedom from abuse or harassment
• Freedom from seclusion and restraint
• Receive an explanation of bill
• Access to hospital rules and regulations
• Transfer to another facility for additional service if needed, and continuity of care
• Notification of admission to family, physicians and others
• Communication in your preferred language
• Be free from discrimination

All Patients Have the Responsibility To:

• Provide accurate information
• Ensure financial arrangements
• Respect rights of others
• Follow their care / treatment plan
• Take responsibility for outcome when care / treatment plan is not followed
• Follow hospital rules and regulations
• Ask questions

You have a right to receive a "Good Faith Estimate" explaining how much your medical care will cost. In the event of receiving emergency care or treatment from an out-of-network provider, you are also protected from surprise or balance billing. More information about these patient rights can be found by clicking the links below:

Good Faith Estimate
Rights and Protections Against Surprise Medical Bill

Hospital Bills and Insurance

If You Have Health Insurance

Your plan may have special requirements, such as a second surgical option or precertification for certain tests or procedures. It is your responsibility to make sure the requirements of your plan have been met. If your plan’s requirements are not followed, you may be financially responsible for all or part of the services rendered at the hospital. Some physician specialists may not participate in your health care plan. Please check with your physician to ensure they are a participating provider in your plan.

Your Health Insurance Plan

We will need a copy of your insurance card, and a photo ID may be required to verify eligibility and process your claim. The hospital will submit your claim to your insurance company and will do everything possible to expedite your claim. You should remember that your policy is a contract between you and your insurance company, and you have the final responsibility for payment of your hospital bill. We have several payment options available to assist you in paying your bill. If you have certain tests or treatments in the hospital, you may receive a bill from physicians you did not see in person. These bills are for professional services rendered by these doctors in diagnosing and interpreting test results while you were a patient. Pathologists, radiologists, cardiologists and other specialists perform these services.

If You Are Covered By Medicare

We will need a copy of your Medicare card, and a photo ID may be required to verify eligibility and process your claim. You should be aware that the Medicare program specifically excludes payment for certain items and services, such as some oral surgery procedures.

If You Are Covered By Medicaid

We will need a copy of your Medicaid card and photo ID may be required. Medicaid also has payment limitation.

If You Have No Health Insurance

A Health Insurance Navigator may reach out to you about plans possibly available to you. You may also discuss financial arrangements with a representative from the Patient Accounts department by calling be 812-885-3325. Financial assistance is available to qualifying patients that do not qualify for other outside assistance programs.

Notice of Health Information Privacy Practices

The notice of Health Information Privacy Practices describes the patient’s rights and certain obligations regarding the use and disclosure of medical information. This notice is provided to the patient at the time of registration.

Quality Concerns

The staff, Board of Governors, physicians and administration of Good Samaritan are committed to providing quality health care for you and your family. If you have concerns related to the overall quality of your care or safety, please call 812-885-3195. If you should require additional follow-up, you may contact The Joint Commission on their website at www.jointcommission.org or call 800-994-6610.

Patient Concern Resolution Process

Good Samaritan has an established Patient Concern Resolution Process. Concerns should be brought to the attention of the Nurse Manager or Director of the involved unit, the Patient and Family Representative or Hospital Administration.

Unresolved concerns will be handled by the Patient Concern Grievance Committee. A grievance may be lodged with the Indiana State Department of Health, regardless of whether or not the patient has first used the hospital’s Patient Concern Resolution Process. The address and phone number of the Indiana State Department of Health are:

Indiana State Department of Health

2 North Meridian Street | Section 4-A

Indianapolis, Indiana 46204

1-800-246-8909

Home Care Services: 1-800-227-6334