All patients should be guaranteed the following freedoms:

• To seek consultation with the physician(s) of their choice;
• To contract with their physician(s) on mutually agreeable terms;
• To be treated confidentially, with access to their records limited to those involved in their care or designated by the patient;
• To use their own resources to purchase the care of their choice;
• To refuse medical treatment even if it is recommended by their physician(s);
• To be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives;
• To refuse third-party interference in their medical care, and to be confident that their actions in seeking or declining medical care will not result in third-party-imposed penalties for
• patients or physicians;
• To receive full disclosure of their insurance plan in plain language, including:
  • CONTRACTS: A copy of the contract between the physician and health care plan, and between the patient or employer and the plan
  • INCENTIVES: Whether participating physicians are offered financial incentives to reduce treatment or ration care;
  • COST: The full cost of the plan, including copayments, coinsurance, and deductibles;
  • COVERAGE: Benefits covered and excluded, including availability and location of 24-hour emergency care;
  • QUALIFICATIONS: A roster and qualifications of participating physicians;
  • APPROVAL PROCEDURES: Authorization procedures for services, whether doctors need approval of a committee or any other individual, and who decides what is medically necessary;
  • REFERRALS: Procedures for consulting a specialist, and who must authorize the referral;
  • APPEALS: Grievance procedures for claim or treatment denials;
  • GAG RULE: Whether physicians are subject to a gag rule, preventing criticism of the plan.

Name
Date
Address
City
State
ZIP