Our agreement

Terms

Membership with Franklin Medical Center is conducted under the following terms.

  • I hereby authorize Franklin Medical Center to contact me using the information I have provided above.
  • I acknowledge and understand that I am voluntarily becoming a Franklin Medical Center patient and that this agreement is non-transferable.
  • I have reviewed the Franklin Medical Center Patient Services Guide, and I have had an opportunity to ask questions and receive answers regarding its content.
  • I understand and acknowledge that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance, and that it provides only the healthcare services specifically described in the Franklin Medical Center Patient Services Guide.
  • I acknowledge and understand that I am responsible for any charges incurred for healthcare services performed outside of Franklin Medical Center including but not limited to emergency room, hospital/specialist/lab services, and that Franklin Medical Center will not bill insurance carriers for any services provided by Franklin Medical Center. I also understand that I may submit charges to my health insurance.
  • I acknowledge and understand that Franklin Medical Center must maintain the privacy of my health information as per the terms of Franklin Medical Center’s Patient Privacy Policy. I understand and acknowledge that this policy is available for my review at any time and upon request.
  • I acknowledge and understand that Franklin Medical Center may terminate this Patient Agreement by providing me written notice. Franklin Medical Center will not terminate this Patient Agreement solely on the basis of health status.
  • I acknowledge and understand that Franklin Medical Center may add or substitute services or ancillary items at any time.
  • I acknowledge and understand that if I am enrolled in Medicare, I will receive a copy of the Medicare Opt-Out Agreement for review and signature before my first appointment. (The Opt- Out Agreement does not prevent me from receiving current or future Medicare benefits from non-Franklin Medical Center providers. Neither I nor my Franklin Medical Center provider(s) will seek reimbursement from Medicare for the medical services I receive from Franklin Medical Center.)
  • I understand that I may terminate this Patient Agreement at any time by providing Franklin Medical Center with written notice, and that upon doing so, services will cease on the last day of the month during which services are cancelled.
  • I understand that I have the right to choose my personal healthcare provider and to change my provider at any time for any reason.
  • I understand that I have the right to receive accurate and easily understood information about Franklin Medical Center’s healthcare services, healthcare professionals, and healthcare facilities. If I speak a language different from my provider, have a physical or mental disability or do not understand something, I understand that Franklin Medical Center will make its best effort to provide assistance so I can make informed healthcare decisions. If I require interpreter services beyond what can be provided by Franklin Medical Center, professional interpreters may be provided at an additional cost to me.
  • I understand that I have the right to considerate, respectful, and nondiscriminatory care from my Franklin Medical Center healthcare provider(s). I also understand that I am responsible for communicating clearly and respectfully with my provider.
  • I understand that I have the right to know all of my treatment options and to participate in my healthcare decisions. Patients, guardians, family members, or other individuals whom I designate may represent me if I cannot make my own decisions.
  • I understand that I have the right to speak in confidence with my Franklin Medical Center provider(s) and to have my healthcare information protected. I also understand that I have the right to review and receive a copy of my personal medical record and may request that my healthcare provider(s) amend my record if I feel it is inaccurate or incomplete.
  • I understand that I have the right to a fair, fast, and objective review of any complaint I have against my healthcare provider(s) or any other staff, including complaints about wait times, operating hours, conduct of personnel, business practices, and adequacy of healthcare services and facilities. Should I become dissatisfied with my care or Franklin Medical Center services, I agree to notify Franklin Medical Center immediately so my concerns may be addresses in a timely manner.
  • I understand that I am responsible for being actively involved in my healthcare decisions and to disclose all relevant information to my Franklin Medical Center provider(s) of any healthcare services I receive outside of Franklin Medical Center (such as emergency room, specialist, or hospital services).
  • I understand that I am responsible for not exposing myself or others to disease or dander. I understand that I can receive information from my Franklin Medical Center provider(s) about protecting the health and safety of myself and others.