Montgomery Gastroenterology / Montgomery Endoscopy Center Patient Rights and Medical Record


A. Patients have the right to be treated with respect, consideration and dignity. Care will be free from all forms of abuse or harassment.
B. Patients have a right to medical and nursing services without discrimination based upon age, race, color, religion, national origin, handicap, disability or source of payment.
C. Patients will be provided a private and safe setting during their medical care.
D. Patients will be provided the name of all physicians and/or staff directly assisting in their care.
E. At their request, patients can be informed of their treating physicians education and credentials.
F. Patient are informed of their right to change their provider if other qualified providers are available.
G. Patients are given the opportunity to participate in decisions involving their health care, except when such participation is contraindicated for medical reasons.
H. Patients will be provided, to the degree known, information concerning their diagnosis, evaluation, treatment, prognosis and possible complications. When it is medically inadvisable to give such information to the patient, the information will be provided to a person designated by the patient or to a legally authorize person in their behalf.
I. When the need arises, reasonable attempts are made for health care professionals and other staff to communicate in the language or manner primarily used by patients.
J. Patients can refuse drugs or procedures and have a physician explain the medical consequence of patient's refusal.
Patients can refuse to participate in research. (You will be asked to give your informed consent prior to participation in such a program and you may refuse to continue in a program that you have previously given informed consent to participate in)
K. Patient's medical records are confidential (except as required by Law or third party contractual agreement) Patient's have access to all information contained in their medical record unless access is specifically restricted by your attending physician for medical reasons.
L. Patients can examine and received a detailed evaluation of their bill.
M. Patients are provided with appropriate information regarding the absence of Malpractice insurance coverage.
N. Patients will be provided written information regarding understanding and executing an advanced directives during first office visit with provider.
O. Patients with grievances or complaints of any kind are within rights to seek the attention of a manager or physician to resolve problem.

Montgomery Endoscopy Center contact persons
Mary Ortega - Office Manager and Compliance Officer 301-942-3550
Joyce M Koh MD, Director of Montgomery Endoscopy Center 301-942-3550

Accreditation Association for Ambulatory Health Care, Inc.
5250 Old Orchard Road, Suite 200
Skokie, IL 60077

Office of Medicare Ombudsman
Call 1-800-MEDICARE or
File Online Complaint form at


Patients are responsible for arriving for an appointment at the appropriate time assigned, and to have designated chaperone to escort them home and stay with the patient for the time designated by Physician, if warranted. If a designated chaperone/ride is not accompanying patient case may be canceled. MEC can not provide transportation for patients. It is the responsibility of the patient to arrange a ride home with a chaperone before the day of the procedure.

Patients are to accept personal financial responsibility for non-covered charges. Patients are also responsible for co-pays at the time of the procedure. Patients are responsible for providing the necessary information to complete insurance claims, and for working with the practice or hospital to make payment arrangements if necessary.

Provide complete and accurate information, to the best of their ability about their health, medications, over-the-counter products, dietary supplements, and any allergies or sensitivities.

After having all questions answered, Patient's will sign an informed consent for surgery and anesthesia prior to the start of the procedure.

Patient is responsible for informing the physician about executed Advanced Directives, medical power of attorneys, or any other directive that might affect care.

Patients are to follow prescribed treatment plan (when to stop eating or drinking before procedures, bowel prep) as prescribed by their health care provider and participate in his/her care if they do not, the physician is within rights to cancel case or dismiss a patient from care. Patients should inform our doctors and staff if they expect problems in following prescribed treatment.

If problems arise after the patient is discharged they are responsible for contacting their physician through our professional answering service by calling our main number. In the event of a medical emergency, the patient will be instructed to call 911 or go to the nearest emergency room.

Patients must ask for additional information or explanation about their health status or treatment when they do not fully understand information and instructions.

Patients are responsible for the conduct of family members while they are at the center. The patient is to be respectful to all staff members and other patients in the center.


If you have questions or would like additional information, please contact the HIPPA Policy Officer for this practice. If you believe your privacy rights have been violated, you may file a written complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.


Privacy Practices


Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information often referred to as your health or medical record, serves as a basis for planning your care and treatment and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.


Unless otherwise required by law your health record is the physical property of the healthcare practitioner or facility that compiled it; the information belongs to you. You have the right to request a restriction on certain uses and disclosures of your information, and request amendments to your health record. This includes the right to obtain a paper copy of the notice of information practices upon request, inspect, and obtain a copy of your health record. You may obtain an accounting of disclosures of your health information, request communications of your health information by alternative means or at alternative locations, revoke your authorization to use or disclose health information except to the extent that action has already been taken.


This organization is required to maintain the privacy of your health information, and in addition, provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. This organization must abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should your information practices change, we will mail a revised notice to the address you have provided. If we maintain a Web site that provides information about our customer services or benefits we will post our new notice on that Web site. We will not use or disclose your health information without your authorization, except as described in this notice.

Examples of Disclosures for Treatment, Payment, and Health Operation

We will use your health information for treatment. For example: Information obtained by a healthcare practitioner will be recorded in your record and used to determine the course of treatment that should work best for you. By way of example, your physician will document in your record their expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations (example varies by practitioner type). We will also provide your other practitioners with copies of various reports that should assist them in treating you.

We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplied used.

We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business Associates
There may be some services provide in our organization through contracts with Business Associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose some or all of your health information to Our Business Associate so that they can perform the job we've asked them to do. To protect your health information, however, we require the Business Associate to appropriately safeguard your information.

(inpatient settings) Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to amember of the clergy and, except for religious affiliation, to other people who ask for you by name.

We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with family
Health professionals, using their best judgment, may disclose to a family member, other relatives, close personal friends or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

(inpatient) We may disclose information to researchers when an institutional review board, that has reviewed the research proposal and established protocols to ensure the privacy of your health information, has approved their research.
Funeral directors
We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Organ procurement organizations
Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation or organs for the purpose of tissue donation and transplant.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund raising
We may contact you as part of a fundraising effort.

Food and Drug Administration (FDA)
As required by law, we may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacement.

Workers compensation
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health
As required by law, we may disclose your health information to public or legal authorities charges with tracking births and deaths, as well as with preventing or controlling disease, injury, or disability.

Correctional institution
Should you b an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals. An inmate does not have the right to the Notice of Privacy Practices.

Law enforcement
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Notice or Privacy availability
This notice will be prominently posted in the office where registration occurs and patients will b provided with a hard copy.

Effective Date
This notice will be effective from April 14, 2003.

Modification & Amendment
This notice may be modified or amended by other documents, upon notification from your healthcare provider.
We recognize that you have a choice for healthcare services, and we are grateful that you have chosen us as your provider.