Patients and Visitors
Patient Rights & Responsibilities
As a patient at the Ashtabula County Medical Center, you have certain rights and responsibilities, which protect you and help us provide you with efficient, quality health care.
Ashtabula County Medical Center takes patient confidentiality and privacy very seriously. In the event you need to request your medical records, we must have your authorization. Please download, fill out and return the form below. Please be sure to mark ATTENTION: Health Information Management on the envelope to asssure the information is directed to the appropriate department.
Release of Information Authorization Notice of Privacy Practices
- To have your personal dignity respected. To the confidentiality of your identifiable health information.
- To enjoy personal privacy and a safe, clean environment and to let us know if you would like to restrict your visitors or phone calls.
- To receive visitors of your choosing that you (or your support person, where appropriate) designate, including a spouse, a domestic partner (including a same-sex domestic partner), or another family member or a friend, and the right to withdraw or deny your consent to receive such visitors at any time.
- To be informed (or your support person to be informed, where appropriate) of your visitation rights, including any clinically necessary restriction or limitation on such rights.
- To designate a support person who will designate visitors on your behalf, should you be unable to do so.
- To be free from all forms of abuse or harassment.
- To access protective and advocacy services.
- To know that restraints will be used only when necessary.
- Cultural and Spiritual Values
- To have your cultural, psychosocial, spiritual, and personal values, beliefs and preferences respected.
- To have access to pastoral and other spiritual services.
- Access to Care
- To receive care regardless of your age, race, color, national origin, culture, ethnicity, language, socioeconomic status, religion, physical or mental disability, sex, sexual orientation, or gender identity or expression, or manner of payment.
- To ask for a change of provider or a second opinion.
- Access to Information
- To make advance directives and have them followed.
- To have your family or a representative you choose and your own physician, if requested, be informed of your hospital admission.
- To know the rules regulating your care and conduct.
- To know that Cleveland Clinic hospitals are teaching hospitals and that some of your caregivers may be in training.
- To ask your caregivers if they are in training.
- To know the names and professional titles of your caregivers.
- To have your bill explained and receive information about charges that you may be responsible for, and any potential limitations your policy may place on your coverage.
- To be told what you need to know about your health condition after hospital discharge or office visit.
- To be informed and involved in decisions that affect your care, health status, services or treatment.
- To understand your diagnosis, condition and treatment and make informed decisions about your care after being advised of material risks, benefits and alternatives.
- To knowledgeably refuse any care, treatment and services.
- To say “yes” or “no” to experimental treatments and to be advised when a physician is considering you to be part of a medical research program or donor program. All medical research goes through a special process required by law that reviews protections for patients involved in research, including privacy. We will not involve you in any medical research without going through this special process. You may refuse or withdraw at any time without consequence to your care.
- To legally appoint someone else to make decisions for you if you should become unable to do so, and have that person approve or refuse care, treatment and services.
- To have your family or representative involved in care, treatment and service decisions, as allowed by law.
- To be informed of unanticipated adverse outcomes.
- To have your wishes followed concerning organ donation, when you make such wishes known, in accordance with law and regulation.
- To request a review of your medical chart with your caregivers during your hospital stay.
- To receive information you can understand.
- To have access to an interpreter and/or translation services at no charge.
- To know the reasons for any proposed change in the attending physicians/professional staff responsible for your care.
- To know the reasons for your transfer either within or outside the hospital.
- Pain Management
- To have pain assessed and managed appropriately.
- To request a listing of disclosures about your healthcare, and to be able to access and request to amend your medical record as allowed by law.
- To know the relationship(s) of the hospital to other persons or organizations participating in the provision of your care.
- Recording and Filming
- To provide prior consent before the making of recordings, films or other images that may be used externally.
- Concerns, Complaints or Grievances
- To receive a reasonably prompt response to your request for services.
- To be involved in resolving issues involving your own care, treatment and services.
- To express concerns, complaints and/or a grievance to your providing hospital personnel. You may do this by contacting your Ombudsman office at:
- Ashtabula County Medical Center, 440.997.6277
- Children’s Hospital, Shaker Campus, 216.444.2544
- Cleveland Clinic, 216.444.2544
- Euclid Hospital, 216.692.7888
- Fairview Hospital, 216.476.4424
- Hillcrest Hospital, 440.312.9140
- Lakewood Hospital, 216.529.7049
- Lutheran Hospital, 216.363.2360
- Marymount Hospital, 216.587.8888
- Medina Hospital, 330.721.5330 South Pointe Hospital, 216.491.6299
- According to hospital policy and our regulatory agency requirements, we are required to inform you that you have a right to file a grievance to the following agencies:
- The Ohio Department of Health at 800.342.0553; email: email@example.com; mail address: ODH, PCSU, 246 N. High St., Columbus, OH 43215
- Ohio KePRO Beneficiary Helpline at 800.589.7337 to report a quality of care concern, disagreement with a coverage decision or to appeal a discharge decision for a Medicare beneficiary; mail quality of care complaint letters to Ohio KePRO, Rock Run Center, Suite 100, 5700 Lombardo Center Drive, Seven Hills, OH 44131
To give us complete and accurate information about your health, including your previous medical history and all the medications you are taking.
To inform us of changes in your condition or symptoms, including pain. Asking Questions and Following Instructions
To let us know if you don’t understand the information we give you about your condition or treatment.
To speak up. Communicate your concerns to any employee as soon as possible — including any member of the patient care team, manager, administrator or ombudsman.
Refusing Treatment and Accepting Consequences
To follow our instructions and advice, understanding that you must accept the consequences if you refuse. Explanation of Financial Charges
To pay your bills or make arrangements to meet the financial obligations arising from your care.
Following Rules and Regulations
To follow our rules and regulations.
To keep your scheduled appointments, or let us know if you are unable to keep them.
To leave your personal belongings at home or have family members take all valuables and articles of clothing home while you are hospitalized.
Respect and Consideration
To be considerate and cooperative.
To respect the rights and property of others
Ashtabula County Medical Center serves many purposes; to improve people's health; treat people with injury or disease; educate doctors, health professionals, patients, and community members; and improve understanding of health and disease. In carrying out these activities, Ashtabula County Medical Center will work to respect the patient's values and dignity.
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