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New Patient
Information and Registration
This section contains everything that a new patient will need from
registration forms to letter of consent.
Download and print Patient Registration Form*
Directions to the MS Center at Holy Name Hospital
Advance Directive*
*Needs to be printed and signed by the new patient. Please bring
documents during first visit.
If you would like all the documents above to be mailed to you
instead, please click here.
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8:43A-16.2 Rights of each patient
1. To be informed of these rights, as evidenced by
the patient’s written acknowledgement, or by documentation by
staff in the medical record, that the patient was offered a
written copy of these rights and given a written or verbal
explanation of these rights, in terms the patient could
understand. The facility shall have a means to notify patients of
any rules and regulations it has adopted governing patient conduct
in the facility.
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2. To be informed of services
available in the facility, of the names and professional status of
the personnel providing and/or responsible for the patient’s care,
and of fees and related charges, including payment, fee, deposit,
and refund policy of the facility and any charges for services not
covered by sources of third-party payment or not covered by the
facility’s basic rate.
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3. To be informed if the
facility has authorized other healthcare and educational
institutions to participate in the patient’s treatment. The
patient also shall have a right to know the identity and function
of these institutions, and to refuse to allow their participation
in the patient’s treatment.
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4. To receive from the patient’s
physician(s) or clinical practitioner(s), in terms that the
patient understands, an explanation of his or her complete
medical/health condition or diagnosis, recommended treatment,
treatment options, including the option of no treatment, risk(s)
of treatment, and expected result(s). If this information would be
detrimental to the patient’s health, or if the patient is not
capable of understanding the information, the explanation shall be
provided to the patient’s next of kin or guardian. This release of
information to the next of kin or guardian, along with the reason
for not informing the patient directly, shall be documented in the
patient’s medical record.
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5. To participate in the
planning of the patient’s care and treatment, and to refuse
medication and treatment. Such refusal shall be documented in the
patient’s medical records.
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6. To be included in experimental research only when the patient
gives informed, written consent to such participation, or when a
guardian gives such consent for an incompetent patient in
accordance with law, rule, and regulation. The patient may refuse
to participate in experimental research, including the
investigation of new drugs and medical devices.
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7. To voice grievances or recommend changes in policies and
services to facilitate personnel, the governing authority, and/or
outside representatives of the patient’s choice either
individually or as a group, and free from restraint, interference,
coercion, discrimination, or reprisal.
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8. To be free from mental and physical abuse, free from
exploitation, and free from use of restraints unless they are
authorized by a physician for a limited period of time to protect
the patient or others from injury. Drugs and other medications
shall not be used for discipline of patients or for convenience of
facility personnel.
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9. To confidential treatment of information about the patient.
Information in the patient’s medical record shall not be released
to anyone outside the facility without the patient’s approval,
unless another healthcare facility to which the patient was
transferred requires the information, or unless the release of the
information is required and permitted by law, a third-party
payment contract, or a peer review, or unless the information is
needed by the New Jersey State Department of Health for
statutorily authorized purposes. The facility may release data
about the patient for studies containing aggregated statistics
when the patient’s identity is masked.
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10. To be treated with courtesy, consideration, respect, and
recognition of the patient’s dignity, individuality, and right to
privacy, including, but not limited to, auditory and visual
privacy. The patient’s privacy shall also be respected when
facility personnel are discussing the patient.
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11. To not be required to perform work for the facility unless the
work is part of the patient’s treatment and is performed
voluntarily by the patient. Such work shall be in accordance with
local, State, and Federal laws and rules.
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12. To exercise civil and religious liberties, including the right
to independent personal decisions. No religious beliefs or
practices, or any attendance at religious services, shall be
imposed upon any patient.
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13. To not be discriminated against because of age, race,
religion, sex, nationality, or ability to pay, or deprived of any
constitutional, civil, and/or legal rights solely because of
receiving services from the facility.
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