Patient Rights & Policies

  • Patient Bill of Rights & Responsibilities

    At Centura Health, we believe that you are in control of your health and the decisions about your health. We are passionately committed to supporting your decisions. At each of our facilities, we have established a Patient Bill of Rights and Responsibilities. Knowing your rights and understanding your responsibilities as a patient will help you make better decisions about your healthcare.

    If you feel your rights are not being protected, we want you to know that all Centura Health facilities maintain formal concern, complaint and grievance procedures. This procedure is delineated within the following Patient Bill of Rights.

    This Bill of Rights and Responsibilities also describes your responsibilities as a patient. Patients who choose to disregard their rights and responsibilities agree to accept the consequences which could jeopardize our goal of providing you a superior patient experience and could impact your quality of care.

    Patient Rights

    Centura Health Hospitals support the rights of all patients across the lifespan including geriatric, adult, adolescent, pediatric, infant and neonatal populations. These rights may be exercised through the patient individually or through their authorized surrogate decision maker.

    You have the right to:

    1. Be informed of your patient rights in advance of receiving or discontinuing care when possible.
    2. Receive care, treatment and visitation regardless of disability,national origin, culture, age, color, race, religion, gender identity, sexual orientation. No one is denied examination or treatment of an emergency medical condition because of their source of payment.
    3. Give informed consent for all treatment, procedures, and/or production of recordings, films or other images when used for other than identification, diagnosis or treatment.
    4. Be informed of your health status/prognosis, including unanticipated outcomes of care and the treatment and services related to serious preventable adverse events.
    5. Participate in all areas of your care plan, treatment, care decisions, and discharge plan.
    6. Receive appropriate assessment and prompt management of your pain.
    7. Be treated with respect and dignity.
    8. Experience personal privacy, comfort and security to the extent possible during your stay.
    9. Be free from restraints or seclusion imposed as a means of coercion, discipline, convenience or retaliation by staff.
    10. Experience confidentiality of all communication and clinical records related to your care. You will receive a copy of our Notice of Privacy Practices to inform you how your personal medical information can be used and disclosed and your rights related to your medical information.
    11. Have access to telephone calls, mail, and other communication devices. Any restrictions to access will be discussed with you, and you will be involved in the decision when possible or appropriate.
    12. Choose a “visitor” who may visit you, including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and you have the right to withdraw or deny such choice at any time. You also have the right to select an identified “support person” who can make visitation decisions should you become incapacitated.
    13. If hospitalized, have the right to designate at least one post-discharge caregiver who will assist you with basic tasks following your discharge and, along with you or your authorized surrogate decision maker, provide consultation on your discharge plan. Designating a post-discharge caregiver does not mean the person you have designated is obligated to care for you.
    14. Be communicated with in a manner you can understand which takes into account your age, language, understanding and ability including, but not limited to, access to
      sign language
      interpreter services and communication aides, at no cost. Such communication will include communication with your companion. 
    15. Have access to pastoral/spiritual care.
    16. Receive care in a safe setting.
    17. Be free from all forms of abuse, neglect, mistreatment, or exploitation.
    18. Have access to protective services (e.g., guardianship, advocacy services, and child/adult protective services).
    19. Request medically necessary and appropriate care and treatment.
    20. Refuse any drug, test, procedure, or treatment and be informed of the medical consequences of such a decision.
    21. Consent to or refuse to participate in teaching programs, research, experimental programs, and/or clinical trials.
    22. Receive information about Advance Directives. Set up or provide Advance Directives and have them followed. Designate an authorized surrogate decisionmaker as permitted by law and as needed.
    23. Participate in decision-making regarding ethical issues, personal values or beliefs.
    24. If hospitalized, have a family member or representative of your choice and your physician promptly notified of your admission to the hospital, upon request.
    25. Know the names, professional status and experience of your caregivers.
    26. Have access to your medical records within a reasonable timeframe.
    27. Be examined, treated, and if necessary, transferred to another facility if you have an emergency medical condition or are in labor, regardless of your ability to pay.
    28. Request and receive, prior to the initiation of non-emergent care or treatment, the charges (or estimate of charges) for routine, usual, and customary services and any co-payment, deductible, or non- covered charges, as well as the facility’s general billing procedures including receipt and explanation of an itemized bill. This right is honored regardless of the source(s) of payment.
    29. Be informed of the hospital’s complaint and grievance procedure and whom to contact to file a concern, complaint or grievance. Note: If you have financial issues or questions, please contact Centura Consumer Operations at 303-486-5400. Toll free: 800-953-0104.
      • Our priority is for you to have a positive patient experience. If your concerns are not being resolved with your immediate care giver or the department manager or administrative staff, please call the Patient Care Representative/Advocate or access the hospital operator by dialing “0”.
      • You may also contact The Health Facilities Division of the Colorado Department of Public Health and Environment or the Kansas Department of Health and Environment and the Office of Civil Rights directly regardless of whether you first used the hospital’s complaint and grievance process.

        The Colorado Department of Public Health and Environment
        4300 Cherry Creek Drive South Denver, CO 80222-1530
        Telephone: 303-692-2827

        The Kansas Department of Health and Environment
        1000 SW Jackson, Topeka, Kansas 66612
        Phone: 785-296-1500

        The Office for Civil Rights 
        Department of Health and Human Services
        999 18th Street, South Terrace, Suite 417
        Denver, Colorado 80202
        Phone: 303-844-2024
        TDD 303-844-3439
        Fax: 303-844-2025
      • If you received care in a hospital, emergency department, home care of hospice and if after speaking with one of their representatives your complaint remains unresolved, you may contact The Joint Commission by mail to:

        Office of Quality and Patient Safety, The Joint Commission
        One Renaissance Boulevard
        Oakbrook Terrace, IL 60181
        Online to: using the “Report a Patient Safety Event link in the “Action Center” on the home page of the website’
        By fax to: 630-792-5636
      • You also have the right to file a complaint with the appropriate oversight boards including the Colorado Board of Medical Examiners, the Colorado Dental and Podiatry Boards and the Colorado Department of Regulatory Agencies. For Kansas hospitals, this includes the Kansas State Board of Healing Arts, the Kansas Board of Nursing and the Kansas office of Health Occupations Credentialing. Contact information will be provided by a hospital representative upon request.
      • If you received care in one of our accredited mammography programs, and had a serious grievance* that you feel was not adequately addressed by the facility, you may fax, e-mail, or mail to:

        Director, Breast Imaging Accreditation Programs
        American College of Radiology
        1891 Preston White Drive 
        Reston, VA 20191-4397

        *A serious grievance is defined by the FDA as “a report of a serious adverse event, which means an event that significantly compromises clinical outcomes or one for which a facility fails to take appropriate corrective action in a timely manner.”

    Patient Responsibilities 

    You have the responsibility to:

    1. Ask questions and promptly voice concerns.
    2. Give full and accurate information as it relates to your health, including prescription and non-prescription medications.
    3. Report changes in your condition or symptoms, including pain, and request assistance of a member of the health care team.
    4. Educate yourself. Learn about the medical tests that are being performed and understand your treatment plan.
    5. Follow your recommended treatment plan.
    6. Be considerate of other patients and staff.
    7. Secure your valuables.
    8. Follow facility rules and regulations.
    9. Respect property that belongs to the facility or others.
    10. Understand and honor financial obligations related to your care, including understanding your own insurance coverage.
  • Patient Grievance Process

    Our priority is for you to have a positive patient experience. If you have concerns, please notify your immediate care giver, their department manager or administrative staff.

    Note: The Patient Grievance Process excludes Patient Account/Billing issues. These issues should be referred to Centura Patient Financial Services at 888-347-3295.

    STEP 1: If hospitalized and if your concerns are not being resolved by those you have been in contact with, please call the Patient Care Representative/Advocate. During after-hours and/or weekends/holidays, please dial the hospital operator "O" and ask to speak with the Nursing Administrative Supervisor, who will seek resolution of your issues.

    When we are unable to resolve issues at the time of the complaint, we follow a grievance process. If determined to be a grievance, the hospital Patient Representative/Advocate, urgent care/emergency center manager, or home care/hospice manager or their designees will provide you written notice of the resolution of the grievance. The written notice will include steps taken on your behalf to investigate the grievance, results of the grievance process, the date of completion and the appropriate hospital contact person.

    Note: Resolution is defined by the patient/family member, and may include a meeting with all involved parties.

    If your care was received in a hospital, urgent care, emergency department, hospice or home care, you may also contact The Health Facilities Division of the Colorado Department of Public Health and Environment or the Kansas Department of Health and Environment directly regardless of whether you first used the facility’s complaint and grievance process.

    The Colorado Department of Public Health and Environment 
    4300 Cherry Creek Drive South Denver, CO 80222-1530
    Phone: 303-692-2827

    The Kansas Department of Health and Environment
    1000 SW Jackson, Topeka, Kansas 66612
    Phone: 785-296-1500

    For reporting complaints related to race, color, national origin, disability, age, sex, religion, creed, ancestry, sexual orientation, and marital status, please follow the Office of Civil Rights Procedures listed below

    STEP 2: If your care was received in a hospital, urgent care, emergency department, hospice or home care you are dissatisfied with the resolution, the matter will be referred for an independent second level review within 3 working days. This second level review will be referred to the Chief Executive Officer(CEO)/Chief Operations Officer (COO) or administrative designee. The CEO/COO or designee will further investigate the issue and provide results to you in writing within 7 days. (If the investigation requires more than 7 days, you will be notified for the reason of this delay and when you can expect a response.) If it is your preference that a second level internal review not be performed the Patient Representative/Advocate can facilitate a referral to the Colorado Department of Public Health, on your behalf .

    If you received care in a hospital, hospital emergency department, home care or hospice and if after speaking with one of their representatives your complaint remains unresolved, you may also contact The Joint Commission:

    The Joint Commission
    Division of Accreditation
    Office of Quality and Patient Safety
    One Renaissance Boulevard
    Oakbrook Terrace, IL 60181
    Phone: 800-994-6610
    Fax: 630-792-5636

    You also have the right to file a complaint with the appropriate oversight boards including the Colorado Medical Board, the Colorado Dental and Podiatry Boards and the Colorado Department of Regulatory Agencies. For Kansas facilities, this includes the Kansas State Board of Healing Arts, the Kansas Board of Nursing and the Kansas office of Health Occupations Credentialing. Contact information will be provided by a facility representative upon request. If you, the patient/family member, are dissatisfied with the report from the hospital CEO/COO or designee, you may contact the Colorado Department of Public Health, Health Facilities Division, 4300 Cherry Creek Drive South, Denver, CO 80246-1530, phone: 303-692-2904. The Patient Representative is available to assist with this referral if requested by you. Upon receipt of the written grievance, the Colorado Department of Health will, within 7 days, notify you that an investigation has been initiated. A report in writing will be made to you and to the hospital as to the State's findings and/or recommendations within 14 days of notification, as according to Colorado Regulatory Statute 25-1-121.

    Civil Rights 
    Centura Health does not discriminate against any person on the basis of race, color, national origin, disability, age, sex, religion, creed, ancestry, sexual orientation, and marital status in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy contact Centura Health's Office of the General Counsel at 303-804-8166 (TTY: 711).

    Review sections for grievance procedures:

  • Patient Representatives

    Every Centura Health hospital provides you with a patient representative to help you have a better hospital experience. Our representatives address and investigate your concerns, and then respond to you and your family with findings and recommendations for how your concerns can be resolved.

    For a listing of your contact person: Patient Care Representative/Advocate.

  • Advance Directives

    Also known as living wills, advance directives outline predetermined actions that should be taken in regards to your health if you are no longer able to make decisions for yourself due to incapacity or illness. These legally binding documents outline your wishes regarding life support, resuscitation and other interventions for both your health care team and your family members.

    Read more about Advance Directives.

  • Notice of Privacy Practices

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This version is effective 9/23/13.

    Download a printable copy of the Centura Health Privacy Practices.

    Your personal medical information is private
    Centura Health understands how important your personal medical information is to you. We know you are concerned with how that information might be used, the way in which it is disclosed and how you can access that information. That is why we've put this document in your hands. It's why the "Privacy Practices" outlined here are so important and why we want to pledge our commitment, at the outset, to respect your personal medical information.

    Our pledge to you
    We understand that your medical information is personal and confidential. We create a medical record of the care you receive because it's our legal obligation, but more importantly because we want to provide you with quality care. Please know we are committed to protecting your personal medical information from any use for which it was not intended.

    In short, the law requires us to:

    • Keep your medical information private.
    • Notify you of our legal duties and privacy practices with respect to your medical information.
    • Follow the terms of the most current notice.

    What this notice is all about
    The information in this document applies to all of your medical records. Please understand that a non-Centura doctor may have different policies or notices regarding the use and disclosure of the medical information created in his or her office. This notice will tell you about the specific ways Centura Health and our facilities may use and disclose your medical information. This notice also describes your rights and the duties we have regarding the use and disclosure of your medical information.

    Adhering to privacy practices
    The U.S. Department of Health and Human Services sponsored the Health Insurance Portability and Accountability Act (HIPAA). HIPAA dictates the medical information privacy practices that health care organizations and their partners are obligated to follow. Centura Health provides health care to our patients, residents, and clients in partnership with many physicians and other professionals and organizations.

    This notice describes Centura Health practices and that of:

    • Any health care professional who treats you at any of our locations
    • All departments and units of our organization
    • All employed associates, staff or volunteers of our organization. This includes staff at our sponsor organizations with which we may share information.
    • Any business associate or partner with whom we share health information

    Be assured that all these individuals and organizations understand that the privacy of your medical information is important, and will be following HIPAA guidelines to ensure that your information is used only as it is intended.

    How your health information can be used & disclosed

    The following is a list of ways in which your personal medical information can be used and disclosed as allowed under HIPAA provisions. Be assured that we will use your information in the most discreet manner.

    Disclosure for health care related purposes
    We may use and disclose your medical information for health care related purposes including:

    • Treatment, such as sending your medical information to a specialist as part of a referral.
    • Obtaining payment for treatment, such as sending billing information to your insurance company or Medicare.
    • Supporting our health care operations, such as comparing patient data to improve treatment methods.
    • Communication with business partners so they may help us to do our jobs. These business partners are required by contract and by law to comply with the provisions of HIPAA and protect your rights as we do.

    Centura Health, the members of its medical staff, and other affiliated health care providers participate in an Organized Health Care Arrangement (OCHA). Participation in an OCHA allows covered entities to, among other things, exchange protected health information with other OCHA participants to provide patient care in a more effective and efficient manner.

    Additionally, Centura Health participates in a health information exchange (HIE) network. HIE provides a way to securely and electronically share patients' clinical information with other physicians and other health care providers participating in the HIE network to provide safer, more timely, efficient, and higher quality care.

    Disclosure to other organizations

    Subject to certain requirements, we may give out your medical information to other organizations without prior authorization for:

    • Public health purposes
    • Research studies
    • Organ donation
    • Emergencies
    • Abuse or neglect reporting
    • Funeral arrangements
    • Workers' compensation purposes
    • Health oversight audits or inspections

    Disclosure to legal agencies
    We also disclose medical information when required by law in response to:

    • Requests from law enforcement agencies in specific circumstances
    • Valid judicial or administrative orders
    • The government, if you are in the military or a veteran
    • National security and intelligence activities
    • Protective services for the President and others

    Disclosure for contact with you
    We also may use your medical information for contact with you, for:

    • Appointment reminders
    • Possible treatment options and alternatives
    • Health-related benefits or services that may be of interest to you

    Disclosure for fundraising purposes
    We may use your name, address, age, date of birth, gender, dates of service, department of service, treating physician, outcome information, and health insurance status:

    • To raise funds for Centura Health or one of our facilities
    • To raise funds for one of our institutionally related foundations

    Please know that our institutionally related foundations are required by law to comply with HIPAA regulations and state confidentiality laws. If you do not wish to be contacted for these efforts please notify the facility according to instructions contained in the materials you may receive.

    Disclosure when you are a patient or resident
    If admitted as a patient or resident, we may list the following information in our facility directory, unless you tell us otherwise:

    • Your name
    • Your location in the facility
    • Your general condition (good, fair, etc.)
    • Your religious affiliation

    We will release all but your religious affiliation to anyone who asks about you by name. Your religious affiliation may be disclosed only to a clergy member, even if they do not ask for you by name.

    Disclosure to friends, family and others
    We may disclose medical information about you to:

    • A friend or family member who is involved in your medical care
    • Someone who helps pay for your care
    • Disaster relief authorities to notify your family of your location and condition

    Disclosure in special circumstances
    Most uses and disclosures of psychotherapy notes, uses and disclosures of your medical information for marketing purposes, and disclosures that constitute a sale of your medical information require authorization. In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing your medical information. If you chose to authorize use or disclosure you can later revoke that authorization by notifying us in writing of your decision.

    Your rights

    Can you see a copy of your medical information?
    In most cases, you have the right to review and obtain a copy of the medical information we use to make decisions about your care by submitting a written request. If you request a paper or electronic copy, we may charge a fee for the cost of copying or electronically scanning, and for mailing or other related supplies. If we deny your request to review or obtain a copy you may submit a written request for a review of that decision.

    What if your medical records are inaccurate?
    If you believe that information in your record is incorrect or if important information is missing, you have the right to request correction of the records by submitting a request in writing along with your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the medical information we maintained; if it is not part of the information you would be permitted to review or copy; or if we determine that the record is accurate. You may appeal, in writing, a decision by us not to amend a record.

    Can you know with whom we've shared your records?
    You have the right to a list of those instances where we have disclosed your medical information, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, by submitting a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and start after April 14, 2003. You may receive the list in paper or electronic form. The first disclosure list request in a 12-month period is free; other requests will be charged according to our production cost. We will inform you of the cost before you incur any expenses.

    Can you specify the way in which we communicate your medical records to you?
    You have the right to request that your medical information be communicated to you in a confidential manner, such as sending mail to an address other than your home. Your request must specify how or where you wish to be contacted. We will attempt to honor all reasonable requests.

    Can you request your medical information only be released with your permission?
    You may request in writing that we not use or disclose your medical information for treatment, payment and health care operations, or to persons involved in your care except when specifically authorized by you, or when required by law or in an emergency. All written requests must tell us (1) what information you want to limit; (2) whether you want to limit our use or disclosure; and (3) to whom you want the limits to apply. Unless your request is to restrict disclosing your medical information to your health plan for health care services for which you pay out of pocket in full, we will consider your request but are not legally required to agree to it. We will inform you of our decision on your request.

    Will you be notified if there has been a breach of your medical information?
    You have the right to, and will, be notified following a breach of your medical information in the event it has not been rendered unusable, unreadable, or indecipherable to unauthorized individuals.

    If you've received this notice electronically, can you receive a paper copy?
    You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may view or print a copy of the notice at Centura Health website.

    Where can you express a concern?
    If you are concerned that your privacy rights may have been violated or disagree with a decision we made about access to your records, you may contact the Centura Health Integrity Helpline toll-free: 888-424-2458. You also may send a written complaint to the U.S. Department of Health and Human Services Office for Civil Rights. Under no circumstance will you be penalized or retaliated against for filing a complaint.

    Will the policies in this notice change?
    We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. When we make a significant change to our policies, we will change this notice and post the current notice in our facility and on our website. The notice will contain the effective date. In addition, you will be offered a copy of the current notice each time you register at one of our facilities for treatment.

    If you have any questions regarding the contents of this Notice of Privacy Practices, please contact the facility main number, ask for the designated privacy officer or call the Centura Health Integrity Helpline toll-free: 888-424-2458.

  • Colorado End-of-Life Options Act

    Centura Health has a long tradition of believing in the sanctity of life, extending compassionate care and relieving suffering. These fundamental values are reflected in the depth and breadth of support and comfort services we offer, including palliative care, hospice care, spiritual care services and mental health services, so patients and their families may live with dignity until the patient’s time of death. Centura Health facilities and providers do not provide medical aid in dying medication or related services.

    Learn more about our position.

  • Colorado Immunization Information System

    Colorado Immunization Information System (CIIS) is a confidential, population-based, computerized system that collects and consolidates vaccination data for Coloradans of all ages from a variety of sources. CIIS helps healthcare providers, schools, childcare centers, universities, and individuals keep track of the shots that they and/or their children have received.

    CIIS is a program within the Colorado Immunization Section at the Colorado Department of Public Health and Environment (CDPHE). CIIS is a lifelong immunization record tracking system under the Colorado Immunization Registry Act of 2007.

    For more information on the CIIS program website.

    To exclude yours or your child’s information from CIIS, visit the CIIS opt-out procedures web page to opt out of the registry. You will also find information on how to rescind a prior opt out.