DAIM NTAWV QHIA TXOG KEV TIV THAIV NTAUB NTAWV MOB NKEES
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1 DAIM NTAWV QHIA TXOG KEV TIV THAIV NTAUB NTAWV MOB NKEES DAIM NTAWV NO QHIA TXOG KEV UAS LAWV SIV TAU KOJ TEJ NTAUB NTAWV UAS QHIA TXOG KOJ TEJ MOB. THIAB QHIA TXOG KEV UAS KOJ SIV COV NTAUB NTAWV NO LI CAS THIAB. THOV MUAB TWM TUAB QUAS ZOO. Peb Teg Dejnum Affinity Health System txaus siab los pab tiv thaiv cov uas tuaj kho mob cov ntaub ntawv mob nkees thiab tej yam ua qhia txog nej tej kev mob kom luas tej yuav tsi paub txog. Nws yeej yog ib txoj kevcai uas peb yuav tsum ua raws: Peb yeej yuav tsum tiv thaiv nej tej ntaub ntawv kom luas tej yuav tsi paub txog koj tej mob nkees tej. Peb yeej yuav tsum qhia rau koj hauv daim ntawv no txog txhua yam uas yog peb dejnum tsaws li kevcai thiab peb tej kev tiv thaiv uas peb muaj rau nej txog nej tej kev mob. Yog hais tias nej muaj lus nus li cas txog ib qho twg ntawm daim ntawv no lossis yog hais tias nej xav paub ntxiv txog tej no tes thov hu tuaj rau tus xovtooj uas nyob tomqab daim ntawv no. Hnub Uas Daim Ntawv No Pib Txhua yam uas hais hauv daim ntawv no yuav pib rau hnub April 14, 2003 thiab nws yuav tsi muaj hloov ruas yog hais tias peb muaj hloov lawm no xwb. Peb yeej muaj cai hloov daim ntawv no tau lub sijhawm tws los tau. Daim ntawv no yeej yog hais txog txhua lub Affinity Health System uas khaws ntaub ntawv rau cov uas tuaj kho mob thiab nws yog lus pab tiv thaiv nej tej ntaub ntawv rau li txhua yam uas peb lub koomhaum khaws tau. Tej yam uas peb tau muab hloov hauv daim ntaub ntawv no peb yeej muab kho kom tiv thaiv rau tej yam uas tag los thiab. Peb yeej yuav muab daim ntawv no lo rau tej qhov chaw hauv peb tej lub tsev kho mob kom nej yuav pom txog thiab. Affinity Health System txaus siab ua lawv raws li daim ntawv uas nyav kho tshiab tshaj. Nej thov tau ib daim ntawv uas nyav kho tshiab tshaj no tau txhua lub sibhawm. Yog hais tias nej thov ib daim ntawv no nua tes peb yuav kom nej sau ib daim ntawv qhia rau peb paub hais tias nej tau txais lawm. Leejtws Yuav Tsum Ua Tsaws Li Peb Daim Ntawv No Affinity Health System yeej pab txog cov uas tuaj kuaj, cov uas nyob ib ncig, cov uas ua dejnum pab peb thiab cov uas kho mob tej tuab quas si. Yog li ntawd mas cov uas yuav tsum ua tsaws li peb tej kevcai no yog: Cov kho mob uas ua dejnum lus pab nej sawdaws Txhua qhov chaw thiab cheebtsam uas ua nrog peb lub koomhaum no tsi yog nyob deb los ze Txhua tus uas ua haujlwm rau peb xws li cov uas khaws ntaub ntawv mus rau cov uas xyaum tshiab mus rau cov uas tseem kawm nws tes dejnum
2 Vim Li Cas Peb Muaj Kev Muaj Cai Tso Nej Tej Ntaub Ntawv Nws yog peb ruaj siab los pab muab nej tej ntaub ntawv siv raws li uas yog kevcai hauv peb lub koomhaum. Yeej muaj tej lub sibhawm uas peb yuav siv nej tej ntaub ntawv uas qhia txog nej tej kev mob rau lwm leej lwm tus uas tsi qhia rau nej thiab. Cov sibhawm nua yog los siv ua li tomqab no: 1. Kev Kuaj: Muaj tej thaum peb yuav siv nej tej ntaub ntawv uas qhia txog nej tej mob nkees los pab rau peb kev kuaj. Thaum uas koj tuaj kuaj rau peb cov chaw kho mob peb yuav siv nej tej ntaub ntawv los pab peb cov uas kho mob mus rau cov nasmaum thiab dua cov uas ua dejnum los pab koj. Peb yuav muab koj tej ntaub ntawv no mus rau dua lub chaw kho mob uas peb xa koj mus kuaj thiab xis li tsev kho mob tej. 2. Them Nyiaj: Muaj tej thaum peb yuav siv nej tej ntaub ntawv uas qhia txog nej tej mob nkees los pab rau peb kev sau saib nej tej qhe tsaug npaum li cas. No yog ib qho uas peb yuav tsum ua es peb thiaj li txais tau nyiaj los ntawm koj lossis koj li insurance lossis dua lwm tus uas tsaug them qhov qhe no rau koj. 3. Kev Tshuaj Mob Nkees: Muaj tej thaum uas peb yuav tsum siv koj tej ntaub ntawv uas qhia txog koj tej mob nkees los rau peb tej kev tshuaj ntawv kom pab tau koj thiab. Pev txwv txog peb kev muab koj tej ntaub ntawv no los pab peb kev khiav dejnum. 4. Kev Paab Rau Koj: Muaj tej thaum peb yuav siv nej tej ntaub ntawv los pab nej kom nco ntsoov nej tej navmaim los qhia nej tej kev kuaj. Peb siv tau tej ntaub ntawv no los pab qhia nej txog tej yam kev pabcuam ua muaj tau los pab nej thiab. Peb kev uas qhia nej yuav yog ntawm kev sau ntawv los kev hu xovtooj. 5. Kev Nrhiav Cov Tuaj Kho Mob: Muaj tej thaum uas peb siv nej lub npe thiab chaw nyob tej rau hauv nej tej ntaub ntawv los pab peb. Peb yuav qhia tej no rau peb cov xibhwb tej thiab rau tej tus uas tuaj nrhiav nej rau hauv tsev kho mob. Yog hais tias nej tsi xav kom luas tej li tus xibhwb los luas tej uas tuaj nrhiav nej paub nej lub npe thiab chaw nyob tej no tes yuav tsum qhia rau peb paub es peb thiaj muab hloov tau. 6. Kev Qhia Rau Tsev Tibneeg Thiab Cov Phoojyws: Muaj tej zaum peb yuav siv nej tej ntaub ntawv los pab qhia rau nej tej tsev tibneeg lossis nej cov phoojyws uas pab tu nej. Yog hais tias nej txiav txim tsi tau rau nej tus kheej no tes tus uas kho mob mam li txiav txim kev uas qhia rau nej tsev tibneeg rau nej. 7. Tsaws Li Kevcai: Peb yuav siv nej tej ntaub ntawv tsaws li kevcai pub xwb. Pev txwv txog tej yam uas tsaws li kevcai peb yuav tsum tso nej tej ntaub ntawv mus yog: a. Rau tej yam uas yog rau public health kej tshuaj ntawv tej thiab rau lub koomhaum Food & Drug Administration (FDA) b. Rau tej yam li uas thaum uas peb paub hais tias muaj kev ntaus tibneeg pem tsev c. Rau tej yam kev tsuaj txog kev saib xyuas kev kho mob nkees d. Rau tom tsev hais plaub tej e. Rau tub ceevxwm tej kev ua haujlwm xws li kev uas tshawb txog kev ploj tuaj tej los nrhiav tej tus tibneeg uas ua txhaum f. Rau cov uas kho mob uas kuaj cov uas tuag lawm los rau cov uas tswj tsev txiag g. Rau kev uas pub yus tej plawv, siab, los qhovmuas tej (organ donation) h. Rau kev tiv thaiv luas leej lwm tus yog hais tias yus muaj tej yam uas yuav tsi zoo rau lawv tej i. Rau tej yam uas yuav pab kev tswj fwm (government) xws li kev ua tub rog tej j. Rau tej lub tsev kaw cov tibneeg uas tsaug txim yog hais tias nws tseem nyob rau hauv qhov taub k. Rau tej yam uas yog tim kev tsaug mob rau tim chaw ua dejnum (worker s compensation)
3 8. Kev Tshuaj: Muaj tej zaum peb yuav siv nej tej ntaub ntawv los pab rau peb tej kev tshuaj ntaub ntawv. Txawm yog peb siv los ua tej no los peb yeej yuav tsi muaj qhia tawm rau lawv tej paub. 9. Kev Nrhiav Nyiaj: Muaj tej zaum peb yuav siv nej tej npe thiab chaw nyob tej rau thaum uas peb xaa ntaub ntawv los qhia nej txog peb tej kev nrhiav nyiaj. Yog muaj li no tes peb yuav muaj tau nej tej npe rau peb cov koomhaum uas nrhiav nyiaj tej thiab. Yog hais tias nej tsi xav kom Affinity Health System siv nws rau yam no tes thov qhia rau peb paub thiab. 10. Kev Pab Tej Yam Xwm Txheej Loj: Muaj tej zaum peb yuav siv nej tej npe thiab chaw nyob tej rau thaum tau muaj tej yam xwm txheej loj uas tau tshwmsim. Qhov no yog pab rau lawv tej raws li kevcai hais tias nws yog ib qho uas yuav pab tau xwb. Lwm Yam Uas Peb Yuam Tsum Siv Nej Tej Ntaub Ntawv Yog hais tias muaj lwm yam uas tshwmsim uas peb tsi hais rau hauv daim ntawv no nua los peb yeej yuav tsum sau ib daim ntawv qhia rau nej paub ua ntej saib nej puas yuav tso cai rau peb qhia tej yam ntawd tawm rau lawv tej paub. Yog hais tias nej tau tso cai rau peb lawm no tes yog hais tias nej hloov siab no los thov sau ntawv qhia rau peb paub es peb thiaj li tsi tso nej tej ntaub ntawv no tawm. Cov Cai Uas Koj Muaj Hais Txog Koj Tej Ntaub Ntawv Vim hais tias koj yog ib tus uas tuaj kho mob rau Affinity Health System no koj muaj cai thaum uas hais txog koj tej ntaub ntawv uas hais txog koj tej mob nkees tej uas peb tau khaws cia ntawm peb lub koomhaum. Koj cov cai muaj li tomqab no: 1. Kevcai Uas Muab Tau Tej Ntaub Ntawv: Koj yeej muaj txoj cai uas muab tau koj tej ntaub ntawv uas hais txog koj tej mob nkees. Thaum uas koj thov tej ntaub ntawv no koj yuav tsum sau ntawv tuaj rau peb es peb thiaj li tso tau cov ntaub ntawv no tawm mus. Yog hais tias koj tau thov kom luam koj tej ntawv no tes thov hais rau peb ua ntej lub sibhawm uas koj yuav thiab tej zaum yuav muaj ib tus nqe rau koj los pab peb kev xaa ntawv tej. Muaj tej feem tshawg uas peb yuav tsi pub tso koj tej ntaub ntawv no tawm thiab. Yog hais tias peb tsi pub tso koj tej ntaub ntawv no los peb yeej yuav tsum qhia rau nej paub thiab peb yeej qhia rau nej paub hais tias nej muaj txoj cai lus muab qhov no los saib thiab hais txog. 2. Kev Khaws Ntaub Ntawv: Koj muaj cai thov tau ib daim ntawv uas qhia txog koj cov ntaub ntawv uas peb tau tso rau lawv tej uas Affinity Health System tau qhia txog nej tej mob nkees. Thaum uas koj thov tej ntaub ntawv no koj yuav tsum sau ntawv tuaj rau peb es peb thiaj li tso tau cov ntaub ntawv no tawm mus. Koj kev thov tej ntaub ntawv no yuav tsum muaj lub sibhawm uas koj thov saib thiab tsi pub dhau 6 lub xyoo thiab tsi pub nws ua ntej lub April 14, 2003 no. Yog hais tias nej thov saib nej tej ntaub ntawv hauv ib lub xyoo no xwb tes tsi muaj nqe tiab si yog hais tias ntev dua qhov ntawd no tes yuav muaj nqe tshawb nej tej ntaub ntawv thiab. 3. Kev Kho: Koj muaj txoj cai thov kom peb kho koj tej ntaub ntawv uas hais txog koj tej mob nkees yog hais tias koj xaa hais tias nws qhia tsi tag los nws tsi thwj. Thaum uas koj thov tej ntaub ntawv no koj yuav tsum sau ntawv tuaj rau peb. Affinity Health System mam li saib koj kev thov no thiab mam li txiav txim siab saib puas yuav muab kho. Yog hais tias peb xaa hais tias nws yuav tsi yog ib qho uas peb yuav kho tau no los peb muaj txoj cai uas tsi kho thiab. Affinity Health System mam li sau ntawv qhia rau nej paub hais tias txiav txim tau li cas lawm thiab yeej qhia rau nej paub hais tias nej muaj txoj cai lus muab qhov no los saib thiab hais txog.
4 4. Kev Hais Twb Ywv: Koj muaj txoj cai kom peb qhia koj txog koj tej mob nkees twb quas ywv los rau dua lwm qhov chaw los tau thiab. Koj yuav tsum sau ntawv qhia rau peb paub hais tias koj xav kom peb qhia koj twb ywv thiab koj yuav tsum sau txog hais tias vim li cas es koj xav kom peb muab hais twb ywv lossis qhia qhov no rau peb paub ntawm ntsejmuas. Peb muaj txoj cai los txiav txim hais tias nws puas yog ib qho uas peb yuav muab hais tau twb quas ywv thiab. Peb muaj cai tsi ua tsaws li uas nej tau xaj thiab yog hais tias nws tsi yog ib qho uas ncaj. 5. Tej Kev Txwv: Koj muaj txoj cai txwv tsi pub peb qhia tej yam uas hais txog koj tej mob nkees thiab. Koj yuav tsum sau ntawv qhia rau peb paub txog tej no. Peb mam li muab koj kev thov no los saib seb nws puas yog ib qho uas peb yuav ua tau los tsi tau. 6. Kev Qhia: Koj muaj txoj cai tau ib daim ntawv qhia no. Koj thov peb muab ib daim ntawv no tuaj rau koj tau lub sibhawm tws los tau lossis koj luam tau ib daim tawm ntawm peb qhov website uas yog Tej Lus Nug Thiab Kev Tsi Txaus Siab Yog hais tias koj xav tau txim txog peb cov kev tiv thaiv nej tej ntaub ntawv no los yog hais tias koj xav tau ib yam dabtsi uas hais txog koj tej ntaub ntawv mob nkees nua tes thov qhia rau peb paub thiab. Peb qhov chaw nyob thiab xovtooj tej nyob rau ntsag qab daim ntawv no. Yog hais tias koj muaj kev txhawj txog hais tias koj tsi txaus siab rau ib qho uas peb tau uas lawm lossis koj tsi txaus siab rau peb kev txiav txim li cas no los koj muaj cai hais tuaj thiab. Koj siv qhov chaw nyob thiab xovtooj uas nyob rau ntsag qab daim ntawv no los hais txog koj tej kev tsi txaus siab. Koj yuav tsum sau tej kev tsi txaus siab no tuaj. Koj xaa ib daim ntawv tsi txaus siab tau rau Secretary of the U.S. Department of Health and Human Services Office of Civil Rights. Peb mam li muab puab qhov chaw nyob rau koj xaa ntawv mus rau lawv yog hais tias koj thov tau qhov chaw nyob rau U.S. Department of Health and Human Services. Peb yeej yuav pab koj tsaws li koj tej cai uas koj muaj txog koj tej ntaub ntawv mob nkees. Peb yeej yuav tsi chim los khwv tswvyim phem rau koj yog hais tias koj xav sau ntawm hais txog peb rau U.S. Department of Health and Human Services. Yog hais tias koj xav nrog peb tham tej los tau dabtsi no tes siv qhov chaw nyob thiab xovtooj tomqab no: Affinity Health System Privacy Officer 1506 South Oneida Street Appleton, WI Xovtooj: (920) los (877)
5 DAIM NTAWV QHIA HAIS TIAS TAU TXAIS DAIM NTAWV QHIA TXOG KEV TIV THAIV NTAUB NTAWV MOB NKEES Thaum koj sau npe rau daim ntawv no koj qhia rau Affinity Health System hais tias koj tau txais daim ntawv qhia txog kev tiv thaiv ntaub ntawv mob nkees uas hais txog: Peb kev tiv thaiv uas peb muaj rau koj ntawm kev qhia thiab tso koj tej ntaub ntawv mob nkees rau lawv tej Koj kev muaj cai uas hais txog koj tej ntaub ntawv mob nkees ntawd Peb yuav tsum kom koj sau npe rau daim ntawv no thawj zaum uas peb tau paab koj tomqab hnub April 14, No yog hais txog thawj zaum uas peb tau pab koj txawm yog hais tias tsi yog tim ntsej tim muas no los yuav muab thiab. Yog hais tias thawj zaum peb paab koj yog thaum koj tau tuaj kho mob vim hais tias nws yog ib qho mob ceev uas yog emergency no los peb yuav tsum kom koj sau npe tomqab uas koj zoo zog ntawd. Tus Tuaj Kho Mob/lossis Tus Saib Xyuas Hnub Tim (Qhov no yog rau cov uas dejnum sau yog hais tias daim ntawv no tsi tau sau npe los ntawm tus uas tuaj kho mob lossis ib tus saib xyuas tus ntawd.) Staff member should complete if Acknowledgement Form was not signed by patient/legal representative 1. Does patient have a copy of the Privacy Notice? o Yes o No Why: 2. Please explain why the patient was unable to sign an acknowledgement form or why it was not possible to obtain the patient s signature: o Patient/Legal Representative Left Before Signature Obtained o Emergency/Urgent Admission With Patient Not Present for Registration o Patient By-passed Registration Not Available o Patient Unable to Comprehend o Patient Communication Barrier Existed o Legal Representative (Guardian) of Patient Not Available o Other: 3. Completed By: Patient Acknowledgement Updated in System: Route Completed Form To: o Yes
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