Notice of Patient Rights and Responsibilities (Arizona)

Pure Infusion of Arizona is committed to providing safe, respectful, and high-quality care. This Notice describes the rights and responsibilities of every patient receiving care at this outpatient treatment center, consistent with Arizona law — including Arizona Administrative Code Title 9, Chapter 10, Article 10 (Outpatient Treatment Centers), specifically A.A.C. R9-10-1008 (Patient Rights), and applicable federal requirements — as well as the policies of this facility.

This Notice is posted on the premises, and a written copy is provided to every patient or the patient’s representative at the time of admission, as required by A.A.C. R9-10-1008(A). Please ask a staff member if you would like this Notice in an alternate language or format, or assistance understanding it.

YOUR RIGHTS AS A PATIENT

As a patient of Pure Infusion of Arizona, you have the right to:

1. Be treated with dignity, respect, and consideration.
2. Not be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis.
3. Receive treatment that supports and respects your individuality, choices, strengths, and abilities.
4. Receive privacy in treatment and in the care of your personal needs.
5. Review, upon written request, your own medical record, consistent with A.R.S. §§ 12-2293, 12-2294, and 12-2294.01.
6. Receive a referral to another health care institution if this outpatient treatment center is not authorized or able to provide the physical health or behavioral health services you need.
7. Participate, or have your representative participate, in the development of and decisions concerning your treatment.
8. Participate in, or refuse to participate in, research or experimental treatment.
9. Receive assistance from a family member, your representative, or another individual in understanding, protecting, or exercising your rights.
10. Be free from abuse, neglect, exploitation, coercion, manipulation, sexual abuse, and sexual assault.
11. Be free from restraint or seclusion except as permitted by A.A.C. R9-10-1012(B), and free from restraint that is not necessary to prevent imminent harm to yourself or others.
12. Be free from retaliation for submitting a complaint to Pure Infusion of Arizona, the Arizona Department of Health Services, or another entity.
13. Be free from misappropriation of your personal and private property by any personnel member, employee, volunteer, or student of this facility.

CONSENT, TREATMENT, AND INFORMATION

Except in an emergency, you or your representative:

1. May consent to or refuse treatment.
2. May refuse or withdraw consent for treatment before it is initiated.
3. Will be informed of alternatives to a proposed psychotropic medication or surgical procedure, and the associated risks and possible complications of that medication or procedure.
4. Will be informed of this facility’s policy on health care directives and of the patient complaint process.
5. Will be asked to consent before being photographed, except for photographs taken at admission for identification and administrative purposes.
6. Will be asked to provide written consent before your medical or financial records are released, except as otherwise permitted by law.

YOUR RESPONSIBILITIES AS A PATIENT

To help us provide safe and effective care, we ask that you:

1. Provide accurate and complete information about your health history, medications, allergies, and current condition, to the best of your knowledge.
2. Ask questions when you do not understand your diagnosis, treatment plan, or instructions.
3. Follow the treatment plan you have agreed to, and tell your care team promptly if you are unable or unwilling to follow it.
4. Keep scheduled appointments and notify the clinic as far in advance as possible if you need to cancel or reschedule.
5. Inform staff promptly of any changes in your condition, including new symptoms or reactions during treatment.
6. Treat clinic staff, other patients, and visitors with courtesy and respect.
7. Provide current insurance and billing information and fulfill your financial obligations for services received.
8. Follow clinic safety and infection-control policies.

HOW TO VOICE A CONCERN OR FILE A COMPLAINT

If you have a concern about your care, please speak with your care team or clinic manager so we can address it promptly. You may also contact Pure Infusion of Arizona’s Compliance Department at (801) 921-6305 or email [email protected].

You also have the right to file a complaint directly with the Arizona Department of Health Services, Division of Licensing Services, without first raising the concern with Pure Infusion of Arizona, and without fear that doing so will affect your care:

Arizona Department of Health Services — Division of Licensing Services: 1-800-221-9968
Address: 150 North 18th Avenue, Phoenix, AZ 85007
Website: azdhs.gov

Concerns involving suspected discrimination may also be directed to the U.S. Department of Health and Human Services, Office for Civil Rights (1-800-368-1019), or the Arizona Attorney General’s Civil Rights Division.