Consent to Treatment/Patients' Rights and Responsibilities

Purisima Family Medicine is dedicated to providing you with the best in health care. Along with technical expertise, we want to provide you with a positive patient experience. We respect your rights as a patient and want you to understand your responsibility as a partner in your care.

Consent to Treatment

I voluntarily authorize the rendering of such care, including diagnostic procedures and medical treatment, by authorized agents and employees of the Purisima Family Medicine, its medical staff and their designees, as may in their professional judgment be deemed necessary or beneficial. I acknowledge that no guarantees have been made as to the effect of such examination or treatment on my condition or the condition of the person for whom I am duly authorized to sign. I understand that I have the right to make decisions concerning my health care or the health care of the person for whom I am duly authorized to make such decisions, including the right to refuse medical and surgical procedures.

This consent to treatment may be revoked in writing at any time by the patient or duly authorized agent.

Patients' Rights

Purisima Family Medicine is committed to providing you with respectful care as we meet your health care needs. For this reason, we want you to have a summary of your rights as a patient.

• You have a right to considerate and respectful care.
• You have the right to participate in the development and implementation of your plan of care.
• You have a right to services in a culturally competent and non-discriminating manner including limited English proficiency, reading skills, and/or diverse cultural or ethnic background.
• Patient race, ethnicity, national origin, sex, age, sexual orientation, disability or source of payment does not influence provision of health services.
• You have the right to information about your diagnosis, condition and treatment, in terms that you can understand.
• You have the right to refuse treatment to the extent permitted by law and to be informed of the possible consequences of the refusal.
• You have the right to make or have a representative of your choice make informed decisions about your care.
• You have the right to formulate advance directives and have them followed.
• You are entitled to information about rules and regulations affecting your care or conduct.
• You have the right to express concerns or grievances regarding your care to the office.

Patients' Responsibilities

This is a summary of your responsibilities as a patient at Purisima Family Medicine.

• It is your responsibility to provide accurate and complete information about all matters pertaining to your health, including medications and past or present medical problems.
• You are responsible for following the instructions and advice of your health care team. If you refuse treatment or do not follow the instructions or advice, you must accept the consequences of your actions.
• It is your responsibility to notify a member of the health care team if you do not understand information about your care and treatment.
• You are responsible for reporting changes in your condition or symptoms, including pain, to a member of the healthcare team.
• It is your responsibility to act in a considerate and cooperative manner and to respect the rights and property of others.
• You are responsible for following the rules and regulations of the health care facility.
• You are expected to keep your scheduled appointments or to cancel them in advance if at all possible.
• It is your responsibility to pay your bills or make some arrangement with the facility to meet your financial obligations.

Questions or Concerns

You and your family should feel you can always voice your concerns. If you share a concern or complaint, your care will not be affected in any way. The first step is to discuss your concerns with your doctor, nurse or other caregiver. If you have concerns that are not resolved, please contact Office Manager.

Discrimination is Against the Law and is Not Tolerated in This Medical Practice  

In accordance with the ethical standards of the medical profession, [Practice Name] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Our practice also does not exclude people or treat them differently due to race, color, national origin, age, disability, or sex.  We provide the following:

• Free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, please inform our practice: [Practice Name] [Contact Person] [Mailing Address], [Telephone number ], [TTY number—if covered entity has one], [Fax], [Email].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf , or by mail or phone at:

(800) 368-1019, or 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

ATENCIÓN:  si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.  Llame al 650 560 0216

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 650 560 0216

CHÚ Ý:  Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.  Gọi số 650 560 0216

PAUNAWA:  Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.  Tumawag sa 650 560 0216

주의:  한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.  650 560 0216 번으로 전화해 주십시오. 

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توجه: اگر به زبان فارسی گفتگو می کنید، تسهیلات زبانی بصورت رایگان برای شما فراهم می باشد 6505600216 تماس بگیرید.

ВНИМАНИЕ:  Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.  Звоните 650 560 0216

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。650 560 0216 まで、お電話にてご連絡ください。

ملحوظة:  إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان.  اتصل برقم (رقم هاتف الصم والبك65056002160  

ਧਿਆਨ ਦਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 6505600216'ਤੇ ਕਾਲ ਕਰੋ।

ប្រយ័ត្ន៖  បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, សេវាជំនួយផ្នែកភាសា ដោយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។  ចូរ ទូរស័ព្ទ 6505600216

LUS CEEV:  Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj.    Hu rau 6505600216

ध्यान दें:  यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं 6505600216

कॉल करें।เรียน:  ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี  โทร 6505600216.