Grievance/Complaints

Memorial Village Emergency Room strives to be the first in quality, service and healthcare. The Room recognizes the rights of patients to express their concerns regarding the care and services they receive and to have the complaint addressed in a timely fashion.

Patient complaints are very important and provide the emergency Room with opportunities for improvement in service and care. You will be treated with respect, dignity and courtesy at all times, and please be assured that we will take your concerns very seriously.

The staff is responsible for addressing your complaint promptly at the time it was made. If your complaint cannot be resolved at that time your complaint is considered a grievance.

If you have a grievance you can call Tiffany Gass, Facility Administrator at (281) 496-6837.

The emergency room will attempt to resolve your grievance as soon as possible and you will receive a written notice of the grievance determination within 7 days. You have the right to appeal a grievance determination, and you will be notified within 30 days of appeal notification of the final determination.

You may also submit your grievance to: Department of State Health Services, 1100 West 49% Street, Austin, Texas 78756.

Tiffany Gass
Facility Administrator
Memorial Village Emergency Room

As a patient you have the right to:

• Treatment regardless of your race, national origin and ability to pay.

• Information necessary to help you make treatment decisions in partnership with your physician.

• Information on and involvement in resolving dilemmas about care, treatment and services including unanticipated outcomes. If dilemmas occur and need assistance in their resolution, the emergency Room will provide an ethics consultation to assist with recommendations for resolution.

• Access, request amendments to, and receive an accounting of disclosures regarding your health information as permitted by law.

• Have your cultural, psychosocial, spiritual and personal values, beliefs, and preferences respected.

• Care that provides comfort and dignity through treatments based on the wishes of you or your appointed decision maker.

• Be informed of any human experimentation or other research or educational projects affecting your care or treatment.

• Refuse to accept treatment, and be informed of the medical consequences of any refusal to accept treatment.

• To be free from the use of any form of restraint, physical and chemical, except in an emergency situation when ordered by your physician when necessary to protect you from injuring yourself or others.

• The name of your attending physician, the names of all other practitioners directly participating in your care and the names and functions of other health care persons having direct contact with you.

• Have protective services offered to you, for example guardianship or protective services through county agencies.

• Prepare an advance directive and appoint someone to make healthcare decisions on your behalf as allowed by law.

• Effective management of pain when appropriate.

• Register a complaint/grievance about care or treatment at (281) 496-6837 and receive a response to your concerns.

• You may also submit your complaint/grievance to:

Department of State Health Services, 1100 West 49″ Street, Austin, Texas 78756

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION

We may use your protected health information, or disclose it to others, for a number or different reasons. This notice describes these reasons. For each reason we have written a brief explanation. We also provide some examples. These examples do not include all of the specific ways we may use or disclose your information. But any time we use your information, or disclose it to someone else, it will fit one of the reasons listed here.

1. Payment.

   We will use your protected health information, and disclose it to others, as necessary to make payment for the health care services you receive. For instance, an employee in our claims-processing department may use your protected health information to pay your claims. We will also send you information about claims we pay and claims we do not pay (called an “explanation of benefits”), The explanation of benefits will include information about claims we receive for the Insured and the dependent who are enrolled together under a single contact or identification number. Under certain circumstances, you may receive this information confidentially: see the “Confidential Communication” section in this notice, We may also disclose some of your protected health information to companies with whom we contract for payment-related services. For instance, if you owe us money, we may give information about you to a collection company with whom we contact to collect bills for us. We will not use or disclose more information for payment purposes than is necessary.

2. Health Care Operation.

   We may use and disclose your protected health information for activities that are necessary to operate this organization. This includes reading your protected health information to review the performance of our staff. We may also use your information and the information of other members to plan what services we need to provide, expand, or reduce, We may disclose your protected health information as necessary to others with whom we contract to provide administrative services. This includes our lawyers, auditors, accreditation services, and consultants, for instance.

3. Legal Requirement to Disclose Information.

   We may use or disclose your information when we are required by law to do so. This includes reporting information to government agencies that have the legal responsibility to monitor the health care system. For instance, we may be required to disclose your protected health information, and the information of others, if we are audited by the state insurance department. We will also disclose your protected health information when we are required to do so by a court order or other judicial administrative practices.

4. Public Health Activities.

We will disclose your protected health information when required to do so for health purposes. This includes reporting certain diseases, births, deaths, and reactions to certain medications, It also includes reporting certain information regarding products and activities regulated by the federal Food and Dmg Administration. It may also include notifying people who have been exposed to a disease.

5. To Report Abuse.

We may disclose your protected health information when the information relates to a victim of abuse, neglect or domestic violence. We will make this report only in accordance with laws that require or allow such reporting, or with your permission.

6. Government Oversight.

We may disclose your protected health information if authorized by law to a government oversight agency (e.g. a state insurance department) conducting audits, investigations, or civil or criminal proceedings.

7. Judicial or Administrative Proceedings.

We may disclose your protected health information in the course of a judicial or administrative proceeding (e.g. to respond to a subpoena or discovery request).

8. Coroners

We may disclose your protected health information to coroners, medical examiners, and/or funeral directors consistent with the law.

9. Organ Donation,

We may use or disclose your protected health information for cadaveric organ, eye or tissue donation.

10. Workers’ Compensation,

We may disclose your protected health information to workers’ compensation agencies if necessary for your workers’ compensation benefit determination.

11. Limited Data Sets.

    We may use or disclose, under certain circumstances, limited amounts of your protected health information that is contained in limited data sets.

12. Amend Protected Health Information.

You have the right to ask us to amend protected health information about you, which you believe is not correct, or not complete. If you want to request that we amend your protected health information you must make this request in writing, it must be signed by either you or your representative, and gives the reason you believe the information is not correct or complete, Your fequest to amend your information must be sent to the address under “Whom to Contact” at the end of this notice, We may deny your request if we did not create the information, if it is not part of the records we used to make decisions about you, if the information is something you would not be permitted to inspect or copy, or if it is complete and accurate.

13. Accounting of Disclosures,

You have a right to receive an accounting of certain disclosures of your information to others. This accounting will list the times we have given your protected health information to others. The list will include dates of the disclosures, the names of the people or organizations to whom the information was disclosed, a description of the information, and the reason. We will provide the first list of disclosures you request at no charge. We may charge you for any additional lists you request during the following 12 months. You must tell us the time period you want the list to cover, To be considered, your accounting request must be in writing, signed by you or your representative and sent to the address under “Whom to Contact” at the end of this notice.

14. Facility Directory.

You have the right to decline listing in the emergency Room’s facility directory.

15. Chaplaincy Request.

You have the right to visits by clergy while being treated, or to decline such visits. Should you desire, we would be happy to notify your minister, priest, rabbi, etc. of your hospitalization. If you do not have a local clergy, we will contact a local clergy for you.

16. Complaints.

You have a right to complain about our privacy practices, if you think your privacy has been violated, You may file your complaint with the person listed under the “Whom to Contact” at the end of this notice. You may also file a complaint directly with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing, must describe the situation giving rise to the complaint and must be filed within 180 days of the date that you know, or should have known, of the event giving rise to the complaint. You will not be subject to any retaliation for filing a complaint.

WHOM TO CONTACT:

Contact the person listed below:

• For more information about this notice, or

• For more information about our privacy policies, or

• If you want to exercise any of your rights, as listed on this notice, or

• If you want to request a copy of our current notice of privacy practices.

Tiffany Gass Memorial Village Emergency Room 14520 Memorial Drive, Suite 4 Houston, Texas 77079 281-496-6837



281-496-6837
info@memorialvilageeR.com

14520 Memorial Drive
Houston, Texas 77079

Level 4	$2000	$1600 – $2200
Level 5	$3500	$3000 – $4000

CRITICAL CARE

CRITICAL CARE (UP TO 74 MIN) $4027.65 CRITICAL CARE (EACH ADDITIONAL $1023.04 30 MIN)

THE FACILITY CHARGES A AN OBSERVATION FEE FOR MEDICAL TREATMENT.

INITIAL OBSERVATION CARE — OBSERVATION CARE $1225 FACILITY / HR MEDIAN OBSERVATION (S1000 – $1400}

OBSERVATION CARE PHYSICIAN DATE SPAN: DAY 1 LEVEL ($1500) LEVEL 2 ($2000) LEVEL 3 ($2500) DISCHARGE $1200 MEDIAN CARE PHYSICIAN: DATE SPAN LEVEL 1 ($1200-$1600) LEVEL 2 ($1800- $2200) LEVEL 3 ($2200-$2800) DISCHARGE (51000-51400)

This facility is an out-of-network [not a participating] provider for all [in any] health benefit plans [plan provider network].

Memorial Village Emergency Department 14520 Memorial Drive, Houston, TX ste 4 Facility Contact: 281-496-6837 Facility Administrator: TiffanyGass

Note: A new House Bill 1941 is taking effect from September 1, 2019 which states… If the price alleged to be unconscionable is more than 200 percent of the average charge for the same or substantially similar care provided to other individuals by a hospital emergency room according to data collected by the Department of State Health, consumer protection division may bring an action under Section 17.47