Patient Rights and Responsibilities

At Community Clinical Services, Inc we believe deeply in the dignity of the individual and in the right of all persons to safe, self-directed, quality healthcare. It is our goal to provide you with considerate and respectful treatment while you are here. We are committed to preserving dignity and honoring personal values by protecting the rights of every patient.

If you are not satisfied with your care, for any reason, please report it immediately to the Patient Representative Department at 777-8208.

YOUR RIGHTS AS A PATIENT:

·    You have the right to receive written information of your rights as a patient.

·         You have the right to appropriate medical care, regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or

expression.

·         You have the right to care that is considerate and respectful of personal values and beliefs.

·         You have the right to personal privacy.

·         You have the right to confidentiality of your clinical records in accordance with the law.

·         You have the right to receive care in a safe environment.

·         You have the right to be free from all forms of abuse or harassment.

·         You have the right to know the identity of individuals providing your care.

·         You have the right to have a family member, friend or other individual of your choice present for emotional support during the course of your stay.

·         You have the right to make informed decisions regarding your care, including pain management.

·         You have the right to participate in the development and implementation of your plan of care.

·         You have the right to request or refuse treatment to the extent permitted by law, or to change your mind regarding your care.

·         You have the right to formulate advance directives regarding your care for when you are unable to make decisions regarding your care.

·         You have the right to access information contained within your clinical record within a reasonable time frame.

·         You have the right to give or withhold informed consent to produce or use recordings, films or other images of you for purposes other than your care.

·         You have the right to be free from restraints or seclusion.

·         You have the right to participate in ethical issues that may arise in the course of your care.

·         You have the right to receive information about clinical experiments, research or educational projects affecting your care or treatment including the expected benefits, potential    discomforts and risks and

alternatives that may also be available.

·         You have the right to appropriate assessment and management of pain.

·         You have the right to receive information in a manner that you understand including the provision of interpreting and translation services or the provision of visual aids or adaptive equipment.

·         You have the right to be informed of the Community Clinical Services complaint / grievance process and to voice complaints/concerns without affecting your care and treatment.

·         You have the right to access protective and advocacy services.

·         You have the right to receive a detailed explanation of your bill.

PATIENT RESPONSIBILITIES:

·         You are responsible for your safety and well-being. We expect you to provide accurate and complete health information in all matters relating to your health and to understand your plan of care.

·         You are responsible for arriving to your scheduled appointments on time, or giving us proper notice if you cannot make it to your appointment.

·         Accept responsibility for the outcomes of refusing treatment or for not following the agreed upon plan of care.

·         Assure that your financial obligations are promptly met.

·         You are responsible for being respectful of the rights of other patients and our staff.

·         Respect the property of others and that of Community Clinical Services Inc.

 NO SURPRISE ACT

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an innetwork facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

 If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

• Your health plan generally must:

·         Cover emergency services without requiring you to get approval for services in advance (prior authorization).

·         Cover emergency services by out-of-network providers.

·         Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

·         Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact:

Maine Bureau of Insurance
34 State House Station
Augusta, ME 04333

207-624-8475 or 800-300-5000

https://www.maine.gov/pfr/insurance

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, call 1-866-620-4781, TTY 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1- 800-985-3059

Pay Your Bill

If your Date of Service is prior to October 1, 2022, please contact our Customer Service team at (877) 727-9190 to make a payment.

If your Date of Service is on or after October 1, 2022, please contact our Customer Service team at (855) 275-9593 to make a payment.