Hospice Patient Rights and Responsibilities

This form is used to inform the patient of his/her rights and responsibilities, in writing and orally, in advance of furnishing care during the initial evaluation visit. Areas addressed are respect and confidentiality, financial responsibilities, self-determination rights, complaint process, and the patient's responsibilities.

This form is left with the patient/family and used as a basis to demonstrate that the written requirement to educate/ inform the patient/family about their rights and responsibilities has been met.

This form may also be used for staff orientation to patient rights and responsibilities.

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