New Patient Information

Patient Rights and Responsibilities

The following basic rights and responsibilities of patients are considered reasonably applicable to all Third Street Family Health Services .

Patient Rights

• Access to Care. Individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated, regardless of race, creed, sex, national origin, or sources of payment for care.

• Respect and Dignity. The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of their personal dignity.

• Privacy and Confidentiality. The patient has the right, within the law, to personal and informational privacy, as manifested by the following rights:

  • To refuse to talk with or see anyone not officially connected with the Third Street Family Health Services.
  • To wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere with diagnostic procedures or treatments.
  • To be interviewed and examined in surroundings designed to assure reasonable visual and auditory privacy.
  • To expect that any discussion or consultation involving their case will be conducted discreetly and that individuals not directly involved in their care will not be present without their permission. To have their medical record read only by individuals directly involved in their treatment or monitoring its quality.
  • To expect all communications and other records pertaining to their care, including the source of payment for treatment, to be treated as confidential.
  • To be placed in protective privacy when considered necessary for personal safety.

• Personal Safety. The patient has the right to expect reasonable safety insofar as the Third Street Family Health Services practices and the environment.

• Consent. The patient has the right to reasonable information and participation in their health care decisions.

• Refusal of Treatment. The patient may refuse treatment to the extent permitted by law.

• Ambulatory Charges. Regardless of the payment source for their care, the patient has the right to request and receive an itemized and detailed explanation of their total bill for services rendered in the Third Street Family Health Services.

• Information. The patient has the right to obtain complete and current information concerning their diagnosis (to the degree known), treatment, and any known prognosis from the practitioner responsible for coordinating their care.

• Communication. The patient has the right of access to people outside the Third Street Family Health Services by means of visitors and by verbal and written communication.

Patient Responsibilities

• Provision of Information: A patient has the responsibility to provide, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health. They are responsible for reporting unexpected changes of their condition to the responsible practitioner. A patient is responsible for reporting whether he comprehends a contemplated course of action and what is expected. 

• Compliance Instructions: A patient is responsible for following the treatment plan recommended by the practitioner primarily responsible for their care. This may include following the instructions of nurses and allied health personnel as they carry out the coordinated plan of care, implement the responsible practitioner’s orders, and enforce the applicable Third Street Family Health Services rules and regulations. The patient is responsible for keeping appointments and, when he cannot do so for any reason, for notifying the responsible practitioner or the Third Street Family Health Services.

• Refusal of Treatment: The patient is responsible for their actions if he refuses treatment or does not follow the practitioner’s instructions.

• Ambulatory Charges: The patient is responsible for assuring that the financial obligations of their health care are fulfilled as promptly as possible.

• Center Rules and Regulations: The patient is responsible for following Third Street Family Health Services rules and regulations affecting patient care and conduct.

• Respect and Consideration: The patient is responsible for being considerate of the rights
  of other patients and Third Street Family Health Services personnel and for assisting in the control of noise, smoking, and the number of visitors. The patient is responsible for being respectful of the property and of the Third Street Family Health Services.

• Pain Management: The patient is responsible for notifying the staff about their needs regarding pain and/or the effectiveness of pain control. As a patient, we expect that you will:

  • Ask your doctor or nurse what to expect regarding pain and pain management.
  • Discuss pain relief options with your doctor or nurse.
  • Work with your doctor and nurse to develop a pain management plan.
  • Ask for pain relief when pain first begins.
  • Help the doctor and nurse measure your pain.
  • Tell the doctor or nurse if your pain is not relieved.

Patient Consent to Treatment

I authorize Third Street Family Health Services and its medical, dental, nursing, and other professional staff members to provide such health care services and administer such diagnostic and therapeutic procedures and treatments as, in the judgment of Third Street Family Health Services’ medical personnel, is deemed necessary or advisable in my care. This includes all routine diagnostic tests and procedures, including diagnostic x-rays, the administration and/or injection of pharmaceutical products and medications, and blood withdrawal for laboratory examination. I understand that no guarantees have been made to me as to the results or effectiveness of treatments or examinations performed by Third Street Family Health Services personnel. Behavioral Health Services may include a mental health diagnostic assessment and psychotherapeutic treatment or referral to another agency for treatment. Third Street Family Health Services makes sure that all staff licensed by the State of Ohio have proper credentials.
Treatment Without Consent: Third Street Family Health Services has the right to treat you without consent in three situations only: 1) Emergencies, 2) When there are communication problems, and the provider believes that the circumstances show implied consent. i.e., loss of consciousness while on Third Street Family Health Services premises, 3) Whenever the provider is legally bound to treat the individual, and we have tried to obtain consent.
Release of Information: I authorize Third Street Family Health Services to use and disclose my health information for the following purposes: (1) to provide for, arrange or coordinate my health care treatment; (2) to enable Third Street Family Health Services to obtain payment for the services it provides to me; and (3) to permit Third Street Family Health Services to carry out ordinary health care and business operations such as quality assurance, service planning, and general administration. I am aware that this authorization to use and disclose information may include information regarding:

• HIV or AIDS
• Alcohol or drug abuse
• Mental illness or any mental health condition
• Sexually transmitted diseases
• Family planning, pregnancy, and abortion
• Genetic tests or genetic disease

I am aware that Third Street Family Health Services may share information with my other medical providers for medical treatment or with a third party for financial payment through electronic means.
Assignment of Benefits: I assign to Third Street Family Health Services all benefits to which I
may be entitled from Medicare, Medicaid, other government agencies, insurance carriers, and other third parties who are financially liable for the medical care and treatment provided by Third Street Family Health Services.
Financial Obligations: I agree that, except as may be limited by law or Third Street Family Health Services’ agreements with third-party payers, in the event of non-payment by a third party for which I have provided an assignment of benefits, I am obligated to pay all amounts due for services provided at Third Street Family Health Services facilities in accordance with the rates and terms of Third Street Family Health Services in effect on the date of service. I agree that I am responsible for applicable copayments, coinsurance, or deductibles.
Consent Change: You have the right to request restrictions or changes to the consent on file. Third Street Family Health Services is not required to agree with your request. Upon agreement, your request will be followed. Services provided prior to the request will not be affected; this includes payments for those services. You understand that Third Street Family Health Services may refuse treatment if this consent is revoked by signing this form. Any use or disclosure other than those for treatment, payment, and healthcare operations will be made only with the patient’s signed agreement. You have the right to review Health Insurance Portability and Accountability Act (HIPAA) privacy practices before.
Federal Tort Claims Act: Third Street Family Health Services and its affiliates are recipients of the Health Resources and Services Administration (HRSA). Each of its locations is covered by the Federal Tort Claims Act (FTCA).
Telehealth: Third Street Family Health Services can interact with patients by videoconferencing in real-time with live video, telephone, or HIPAA-compliant chat/text to provide diagnoses and treatment options. By signing this form, the patient understands:1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. 2) I understand that risks, benefits, and consequences are associated with Telehealth services.
Mandated Reporting: While your confidentiality is important to us, there are a few exceptions where staff may be required to share your information with an outside entity without your consent. Ohio law requires certain professionals to report abuse or evidence of abuse.
If you threaten to hurt yourself or someone else, a mandated reporter is bound by law to take action steps necessary to keep people safe, which may include disclosing enough information to get you the help you need. Also, if abuse, neglect, or exploitation is disclosed or suspected of a minor child, an elderly person, or a person with developmental disabilities, a mandated reporter is bound by law to report their information to the proper authorities.

Your Role as a Patient

As a Patient:

• Tell your doctor about all of your health conditions, allergies, and medications, including prescriptions, over-the-counter, vitamins, and herbals.
• Ask someone you trust to serve as a partner in your care. They can ask questions to learn more about your care.
• Please care for us while we care for you by respecting our associates. We value our relationship with each patient and believe it’s an important part of maintaining a safe, healing environment.

During Your Visit, We Ask That You:

• Watch for assistive devices such as walkers and wheelchairs and move out of the way.
• No cell phones. If you must take a call, leave the room to do so.
• Have your health coverage ID or insurance information available, along with any other material the office will need to serve you.
• Be polite to the office staff.
• Don’t be afraid to ask questions. You should ask your doctor or dentist anything about your medical condition and treatment.

In The Event of A Medical Emergency:

• Please go to the nearest emergency department.
• Third Street has an after hour answering service for non-emergent medical questions.

Safety Information

The Importance of Handwashing

Handwashing with soap removes germs from hands. This helps prevent infections because:

• People frequently touch their eyes, nose, and mouth without realizing it. Germs can get into the body through the eyes, nose, and mouth and make us sick.
• Germs from unwashed hands can get into foods and drinks while people prepare or consume them. Germs can multiply in some types of foods or drinks under certain conditions and make people sick.
• Germs from unwashed hands can be transferred to other objects, like handrails, tabletops, or toys, and then transferred to another person’s hands.
• Removing germs through handwashing, therefore, helps prevent diarrhea and respiratory infections and may even help prevent skin and eye infections.

Third Street Family Health Services is Tobacco-Free

At Third Street Family Health Services, we work to provide a healthy environment for our patients, visitors, and employees. That is why Third Street Family Health Services is a tobacco-free environment. Tobacco use is not permitted inside or outside any Third Street Family Health Services property. The use of e-cigarettes is not allowed.

When indicated, masks must be worn on Third Street Family Health Services properties.

When indicated, to reduce the spread of COVID-19 and other infectious diseases, masks are required to be worn by our patients, visitors, and employees.
If a patient or visitor is ill, we ask that you wear a mask or request one from the check-in desk.