You will be asked to sign a form acknowledging that you have reviewed this form

1. I have the right to be respected and supported.

2. I have the right to be informed about and involved in all aspects of my health care.

3. I have the right to complete confidentiality regarding my medical records.

4. I have the right to care that is considerate and respectful of my personal beliefs and values.

5. I have the right to select or change to any qualified provider that works for DHC.

1. I have the responsibility to report all of my significant health-related conditions that may be relevant to the ability of DHC providers to provide effective patient care.

2. I have the responsibility to truthfully and accurately report earnings, assets, and the insurance status (including Medicaid or Medicare eligibility) of everyone living in my household.

3. I have the responsibility to attend all scheduled appointments and comply with all treatments, referrals, and follow-up recommendations of my healthcare providers.

4. I have the responsibility to behave appropriately towards all DHC staff members.

5. I have the responsibility to notify my healthcare providers of any changes in my condition that may necessitate a change in my treatment plan.

6. I have the responsibility to contact the clinic AT LEAST 1 (ONE) WEEK PRIOR to running out of medication which is provided through the assistance of DHC.

7. I have the responsibility to supply the required documentation needed to receive medication assistance.