Employment Application
Employment Application
Patient Rights You have the right... To have Salt Creek Surgery Center (SCSC) respond to your requests and needs for treatment or service provided that the space is available, and to receive the care that reflects your interests and that has been determined by your physician, and respects your advance directives or your rights to formulate advance directives.   To be informed of the right to care that is respectful, recognizes dignity and is private to the extent possible.   To have patient information treated confidentially based on applicable laws and regulations.   To be involved in making decisions regarding your care, including assessment and management of pain.   To be given information in the language you understand or to have information interpreted.   To give informed consent, that is, to make decisions in collaboration with your physician that involve your health care. Consent may be given by the patient or the patient's legal representative. In order to give consent, the patient will be provided information to include: A. An explanation of recommended treatments or procedures in terms which are understandable. B. An explanation of the risks and benefits of treatment, including the chance of success, mortality risk and serious side-effects. C. An explanation of the alternatives and the risks and benefits of such. D. An explanation of the likely consequences if no treatment is pursued. E. An explanation of the recuperative period, including anticipated problems and anticipated length of recuperation. F. An explanation that the patient or his/her legal representative is free to withdraw consent and discontinue participation in treatment. G. A disclosure statement that the patient's physician is participating in teaching, research, experimental or education projects relating to the patient's case.   To an explanation of admission procedures, that shall include disclosure upon admission, of the facility's policy statement on patient rights, which shall include: A. The right to participate in all decisions involving care or treatment, consistent with state and federal statutes. B. The right to refuse any drug, test, treatment, procedure or treatment consistent with the state and federal statutes, including likely medical consequences of such refusal. C. The right to receive considerate and respectful care in a clean and safe environment, free of unnecessary restraint. D. The right to be informed of the facility's rules and regulations applicable to the patient. E. The right to be informed of the facility's grievance procedure. The Administrator may be reached by calling 630-869-4260. F. The right to file a grievance with the appropriate state agency.   To know the name, professional status and experience of the staff providing care or treatment.   To be informed prior to the initiation of general billing procedures: A. Prior to the initiation of non-emergency treatment, upon request, the patient has the right to be informed of routine, usual and customary charges or estimated charges for service based on an average patient with diagnosis similar to the tentative admission diagnosis of the patient. B. If you have questions, please call our office manager at 630-869-4267 for estimated medical cost information between the hours of 9:00AM and 3:00PM on weekdays. C. Based upon insurance information provided by the patient, the facility shall provide assistance as needed with estimates of co-payments, deductibles or other charges that must be paid by the patient. Such assistance may be obtained weekdays between 9:00AM and 3:00PM by calling the facility Business Office at 630-869-4276. D. The facility may include a disclaimer with the disclosure of any charges. Such disclaimer may include further variables, which may alter any disclosed charge. Any charges prohibited by law or third party payor contract will include a no charge disclaimer in the disclosure.   To be provided with information regarding teaching, research, educational or experimental projects related to your care. You have the right to refuse to participate in such projects.   To have your medical records maintained in confidence and in accordance with the medical staff bylaws, rules, and regulations. You have the right to have access to a copy of your medical record by calling our office manager at 630-869-4276. Patient Responsibilities You have the responsibility... To provide the facility with accurate and complete information about your present complaints and your past health history.   To be considerate of other patients, physicians and facility personnel, and to show respect for the belongings of others and facility property.   To discuss your health problems with only those involved in your care.   To request your records through the facility.   To inquire as to the name and purpose of any personnel caring for you.   To say whether or not you understand a contemplated course of treatment and your obligations in the administration of the treatment.   To cooperate with any research or experimental project in which you consent to participate.   To inform the staff that translation is required.   To provide the facility with the necessary information for insurance processing and to be prompt in payment of facility bills.   To be cooperative during recommended treatment. Nondiscrimination Policy This facility has agreed to comply with the provisions of the Federal Civil Rights Act of 1964 and the Pennsylvania Human Relations Act and all requirements imposed pursuant thereto the end that no person shall, on the grounds of race, color national origin, ancestry, age, sex, religious creed, or disability, be excluded from participation in, be denied benefits of or otherwise be subject to discrimination in the provision of any care or service. Civil Rights SCSC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. SCSC does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Grievance Mechanism SCSC administrative staff is available to help with any concerns or suggestions you may have regarding your stay. Complaints will be investigated and a response provided under the provisions of the facility grievance mechanism. If a grievance or complaint is not solved to the patient's or family's satisfaction, the grievance may be filed in writing with the Illinois Department of Public Health, 525 W. Jefferson Street, Springfield, IL, 62761 or by calling (217) 785-2000. In addition grievances may also be reported to the Office of the Medicare Beneficiary Ombudsman at www.medicare.gov/Ombudsman/resources.asp If dissatisfied with your professional provider, patients or their legal representative may file a complaint with the Illinois State Board of Medical Examiners or the Illinois Podiatry Board. Upon request, the facility shall provide the address of the appropriate board. These boards are prohibited from arbitrating or adjudicating fee disputes. Salt Creek Surgery Center 530 North Cass Avenue Westmont, IL 60559 630-968-1800 Advance Directives An Advance Directive tells your doctor what kind of care you would like to have if you become unable to make medical decisions (you are in a coma, for example). If you are admitted to the hospital, the hospital staff will probably talk to you about advance directives. A good Advance Directive describes the kind of treatment you would want depending on how sick you are. For example, the directives would describe what kind of care you want if you have an illness that you are unlikely to recover from, or if you are permanently unconscious. Advance Directives usually tell your doctor that you don't want certain kinds of treatment. However, they can also say that you want a certain treatment no matter how ill you are. It is the policy of SCSC that any Advance Directives will not be honored. However, we will revive, stabilize and transfer patients to a hospital in a life threatening situation. You may bring a copy of your Advance Directives and it will be placed in your patient chart in the event of an emergency hospital transfer. As a courtesy to our patients, a copy of the State of Illinois' "Statutory Short Form for Powers of Attorney for Health Care" can be provided to you upon request. Language Assistance SCSC provides services to people with disabilities to communicate effectively with us, such as. Qualified sign language interpreters; Written information if other formats can be requested and made readily available, other formats may include (large print, audio, accessible electronics formats, other formats); Provides free language services to people whose language is not English; Qualified interpreters. Information written in other languages. If you need these services please contact the facility Director of Nursing or Business Office Manager. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Salt Creek Surgery Center 530 North Cass Avenue Westmont, IL 60559 630-968-1800 You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Administrator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 independence Avenue SW, Room 509F HHH Building, Washington, DC 20201 800-868-1019, 800537-7697 (TDD) Complaint forms are available at: https://www.hhs.gov/ocr/office/file/index.html Informing Individuals with Limited English Proficiency of Language Assistance Services ATTENTION: If you need foreign language assistance, please call 630-968-1800. [ Top ]