Your physician, who is a member of the Hugh Chatham Memorial Hospital medical staff, has requested your admission to the hospital. When you enter the hospital, for your convenience you may directly report to the appropriate nursing floor as directed by your physician, a Business Services representative will come to your bedside to help expedite your admissions process. This information is necessary for your care and we appreciate your help in answering the questions.
We admit emergency patients at any hour of the day or night.
• Nightgown or pajamas
• Nonskid slippers
• A robe
• Toiletry articles
The hospital provides everything else required for a comfortable stay.
We strongly urge you to leave valuables at home or send them home with a relative. The hospital cannot assume responsibility for the loss of money, jewelry, or other property you keep in your room.
If you have surgery or other procedures planned, the hospital will ask you to give your written consent prior to the procedure. In the case of a minor, the hospital will ask for written permission from a parent or guardian. If you have any questions, please be sure to discuss them with your doctor.
Check out time is 11:00 a.m. Your doctor will arrange your discharge with your nurse who will then help you with your preparation to leave.
Before checking out, the patient or responsible party must visit the Cashier to make payment or arrangements to settle the account. The Cashier’s office is located behind the information desk in the main lobby in the hospital.
Your Ride Home
Please ask the person who is going to drive you home to park in the visitors’ lot at
the south end of the hospital. After you have completed the discharge procedure,
your driver may pick you up at either the front entrance of the hospital or outpatient entrance. A staff member will escort you to the entrance and help you get in the car.
Your Case Manager can help you plan for your discharge.
This includes arrangements for:
• Home care
• Home health nurses, aides, and therapists to visit the patient after hospitalization and provide services.
• Durable medical equipment.
• Home equipment such as a wheelchair, hospital bed, or oxygen.
Business Office Hours are 8:00 a.m. to 4:30 p.m. Monday through Friday.
Any applicable co-pays and deductibles are due at time of service.
Billing Information Provided to Patients After Rendering Services
A summary of charges is provided to patients after discharge. Please allow at least two weeks for this information to be forwarded.
Billing Policy for Patients Without Insurance or With Partial Insurance
Any portion of a bill which is not covered (deductible and/or co-insurance) by insurance is expected to be paid at the time of service. Should payment not be made
at the time of service, payment in full is due upon receipt of the bill.
Payment Arrangements and Credit Extensions
• HCMH will accept monthly arrangements when the patient is unable to pay
• A twenty percent down payment is expected on all credit arrangements.
• For all elective procedures not covered by insurance, an 80% down payment is required before the procedure can be scheduled.
Insurance Companies Which are not Billed
• We do not bill individual insurance which pays the patient directly.
• Upon request, a UB04 billing form will be provided to the patient for billing the individual insurance.
• We accept insurance coverage only up to the amount of the total bill.
• We neither accept nor bill third party liability coverage.
• Settlement offers are not accepted.
A Financial Case Worker can help you determine your eligibility for financial assistance. Please call (336) 527-8370 for more information or an appointment to discuss your options.
Refunds, Overpayments and Coordination Of Benefits
• The Business Office issues refund checks every fifteen days for overpayment
• A check will not be issued if the patient has any outstanding accounts.
• A check will not be issued to patients when insurance overpays unless we have a letter from the insurance company to that effect.
• If the insurance company has a coordination of benefits clause, any over payment will be returned to your insurance company.
Questions About Your Bill
If you have questions or need information about your bill, please call the respective patient representative noted below:
HCMH (336) 527-7000
180 Parkwood Drive
Elkin, NC 28621 Fax (336) 836-3833
Charity Care Policy
Click this link to view the Charity Care Policy
Questions About Additional Bills
Yadkin River Radiology
Your diet, like your medications, treatment, and diagnostic tests prescribed by your doctor, is important. Our Dietary Department serves regular, soft, liquid, and special diets with your health and welfare in mind. A dietitian will visit patients on special diets to provide menu selection within the scope of their diets. The nursing stations can provide light snacks such as juice, milk, and crackers. Please do not eat food brought in by visitors unless you first check with your nurse to make sure the food is allowed on your diet.
The Dining Room, located on the first floor, offers hot meals at these times:
• Breakfast: 6:30 a.m. to 9:00 a.m.
• Lunch: 11:30 a.m. to 1:30 p.m.
• Dinner: 5:30 p.m. to 7:00 p.m.
There are also vending machines around the corner from the Dining Room.
A person who is sitting with a patient and finds it inconvenient to visit the dining room may purchase a guest tray. Just arrange it advance with the Dietary Department (336) 527-7279. A department representative will bring the tray to the room along with the patient’s tray. Please remember that all guest trays must be paid for
Television sets are located in most patient rooms and are controlled from the
Except for special care units, all patient rooms have bedside telephones. Here are helpful tips about using hospital telephones:
• Local calls are free
• To call outside the hospital, dial 9, wait for the dial tone, then dial the number
• For long distance calls within the 336 area:
– Dial 8 and listen for the dial tone
– Then dial 0-336 plus the number
– Wait until the telephone operator
• answers to take your information
• For long distance calls outside of the 336 area:
– Dial 9+0 and listen for the dial tone, or dial 9+00
– Then dial your area code plus the number
– Wait until the telephone operator answers
• If you need an AT&T operator:
– Dial 0 and the hospital switchboard operator will connect you with the
• For a collect call:
– Dial 9 + 1 + 800 + 265-5328
• For information: Dial 0 and the hospital switchboard operator will connect you
A chaplain is available at all times. If you would like to talk with the chaplain,
please ask your nurse to arrange a visit.
The Chapel, located just beyond the main entrance to the hospital, is open 24 hours a day for prayer and meditation.
The Hugh Chatham Gift Shop
On the first floor off the main lobby you’ll find a colorful, attractive gift shop. Staffed by volunteers, the shop offers an excellent variety of gifts, plants, flowers, cards and
personal items. The hours are Monday-Friday, 9:00 a.m. to 8:00 p.m.
Mail, Flowers and Newspapers
A hospital volunteer or a member of the hospital staff will deliver mail, flowers and daily newspapers to your room. If the hospital receives mail for you after you have been discharged, the hospital will forward it to your home address.
Facilities for the Handicapped
Restroom facilities for the handicapped are located on the first floor near the entrance to the hospital.
Hugh Chatham provides free parking for patients and visitors. We ask that you observe special signs reserving handicapped spaces, Radiation Oncology patients, etc.
The front desk at the main entrance to the hospital has free maps of the hospital and surrounding health care services.
1.7 miles S
1101 N Bridge St
3.9 miles SE
I77 & Hwy 67
of Jonesville, NC. 5601
U.S. Highway 21
1540 North Carolina 67 Highway
Holiday Inn Express
1713 NC 67 Hwy
I-77 & Hwy 67 (Exit 82),
3020 Rocky Branch Road,
1. The patient has the right to necessary medical care, regardless of payment source, race, creed, age, sex, or national origin.
2. The patient has the right to participate in the development and implementation of his or her plan of care.
3. The patient or his representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include:
– Being informed of his or her health status,
– Being involved in care planning and treatment,
– Being informed of the risks, benefits, and alternatives to treatment before deciding (especially for research or experimental treatments),
– Being aware of who is authorizing and performing treatments, including any relationships among healthcare providers, and
– Being able to request or refuse treatment.
This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.
4. The patient has the right to formulate advance directives and to have them obeyed. The patient has the right to refuse life-sustaining treatment and resuscitation.
5. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. While in the hospital, the patient has the right to talk and visit with friends and family.
6. The patient has the right to personal privacy. Healthcare should be given with consideration and respect for the patient’s personal values and beliefs.
7. The patient has the right to receive care in a safe setting.
8. The patient has the right to be free from all forms of abuse or harassment.
9. The patient has the right to the confidentiality of his or her clinical records.
10. The patient has the right to access information contained in his or her clinical records within a reasonable time frame.
11. The patient has the right to be free from restraints or seclusion of any form that are not medically necessary. Restraints will not be used as a means of coercion, discipline, convenience, or retaliation by staff.
12. The patient has the right to use the Case Management Department for aide in finding help if it is needed outside the hospital.
13. The patient has the right to file a grievance. Patients are encouraged to share any concern with a member of the Hugh Chatham Memorial Hospital staff.
14. The patient has the right to have pain managed appropriately.
A. The patient has the responsibility to provide, to the best of his/her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, Advance Directives, and other matters relating to his/her health. He/she has the responsibility to report unexpected changes in his/her condition to the responsible practitioner. A patient is responsible for making it known whether he/she clearly comprehends a contemplated course of action and what is expected of him/her.
B. A patient is responsible for following the treatment plan, recommended by the practitioner primarily responsible for his/her care. This may include following the instructions of nurses and allied health professionals as they carry out the coordinated plan of care and implement the responsible practitioner’s orders, and as they enforce the applicable hospital rules and regulations. The patient is responsible for keeping appointments, and when he/she is unable to do so for any reason, for notifying the responsible practitioner of the hospital.
C. The patient is responsible if he/she refuses treatment or does not follow the practitioner’s instructions.
D. The patient is responsible for assuring that the financial obligations of his/her health care be fulfilled as promptly as possible.
E. The patient is responsible for following hospital rules and regulations affecting patient care and conduct.
F. The patient is responsible for being considerate of the rights of other patients and hospital personnel and for assisting in the control of noise, and the number of visitors. The patient is responsible for being respectful of the property of other persons and of the hospital.
G. The patient and family are encouraged to ask questions when they do not understand what they have been told about the patient’s care or what they are expected to do.
H. The dying patient has special needs, which are unique and individual. Hugh Chatham Memorial Hospital staff will provide respectful, responsive patient care, as well as support for the psychological, social, emotional, and spiritual needs of the individual and family that demonstrates respect for the individual’s values, belief system, and life philosophy.
1. Care will be provided to insure the patient’s comfort and dignity.
2. Appropriate treatment will be provided, through following the physician’s orders, for primary and secondary symptoms that respond to treatment as desired by the patient or designated representative.
3. Pain will be managed appropriately, and every effort will be made to keep the patient comfortable. The nursing staff will monitor the patient’s pain, notifying the physician if the patient is uncomfortable.
4. Care will be provided that responds to the patient’s and family’s psychological, spiritual, and cultural value concerns.
a. Nursing staff will provide care and support for the patient and family during the
patient’s illness and death, enabling all involved to cope during the grief process.
b. Hospital chaplain services and social services are available as needed.
c. Staff will contact patient’s minister or other parties, upon request.
What You Should Know
What Are My Rights?
Who Decides About My Medical Care Or Treatment?
If you are eighteen years of age or older and mentally competent, you have the right to make decisions about your medical treatment. You should talk to your doctor or other health care provider about any treatment or procedure so that you understand what will be done and why. You have the right to accept or refuse treatments recommended by your doctor. If you want to control decisions about your health care, even if you become unable to make or to express them yourself, you will need an advance directive.
What is an “Advance Directive”?
Do I Have to Have an Advance Directive? What Happens if I Don’t?
An advance directive is a set of directions you give about the health care that you want if you ever lose the ability to make decisions for yourself. North Carolina has two ways for you to make a formal advance directive. One way is called a living will; the other way is the health care power of attorney.
Making a living will or a health care power of attorney is your choice. If you become unable to make your own decisions, and you have no living will or health care agent (a person named to make medical decisions for you), your doctor or health care provider will consult with someone close to you about your care.
What Is A Living Will?
In North Carolina, a living will is a document that tells others that you want to die a natural death if you are terminally and incurably sick or in a persistent vegetative state from which you will not recover. In a living will, you can direct your doctor not to use heroic treatments that would delay your dying (using a respirator or ventilator, for example) or to stop such treatments if they have been started. You can also direct your doctor not to begin or to stop giving you food and water through a tube, called artificial nutrition or hydration.
Health Care Power of Attorney
What is a Health Care Power of Attorney?
In North Carolina, you can name a person to make medical care decisions for you if you later become unable to decide for yourself. This person is called your “health care agent.” In the legal document, you name who you want your agent to be. You can also state what medical treatments you would want and what you would not want. Your agent then knows what choices you would make.
How Should I Choose a Health Care Agent?
You should choose someone you trust and discuss your wishes with him/her before you put them in writing.
How do I Make an Advance Directive?
You must follow several rules when you make a living will or a health care power of attorney. These rules are to protect you and ensure that your wishes are clear to the doctor or other provider who may be asked to carry them out. Both a living will and health care power of attorney must be written and signed by you while you are still able to understand your condition and treatment choices and to make those choices known. Both types of advance directives must be witnessed by two qualified
people and be notarized.
Are There Forms I Can Use to Make an Advance Directive?
There is a living will form and a health care power of attorney form that you can use. These forms meet all of the rules for a formal advance directive. Using the special form is the best way to make sure that your wishes are carried out.
When Does an Advance Directive Take Effect?
A living will goes into effect when you are going to die soon and cannot be cured, or when you are in a persistent vegetative state. The powers granted by your health care power of attorney go into effect when your doctor states in writing that you are not able to make decisions about your treatment.
What Happens if I Change My Mind?
You can cancel your living will either by destroying all the copies of it or by informing your doctor that you want to cancel it. You can change your health care power of attorney by signing another one or by telling your doctor and each health care agent you named of the change.
Whom Should I Talk to About an Advance Directive?
You should talk to those closest to you about an advance directive and your feelings about the health care you would like to receive. Your doctor or health care provider can answer any medical questions you might have. A lawyer can answer questions about legal issues. Some people also discuss the decision with clergy or other
What if I Have an Advance Directive from Another State?
An advance directive from another state may not meet all of North Carolina’s rules. To be sure of this, you may want to make an advance directive in North Carolina or have your lawyer review the advance directive from the other state.
Where Can I Get More Information?
Hugh Chatham Memorial Hospital honors advanced directives to the extent authorized by North Carolina law.
Your health care provider can tell you how to get more information about advance directives by contacting:
Social Worker on the second floor of the South
Wing Ext. #7200
This document has been developed by the North Carolina Division of Medical Assistance in cooperation with the Department of Human Resources Advisory Panel on Advance Directives.
Hugh Chatham Memorial Hospital
180 Parkwood Drive
Elkin, North Carolina 28621
Hugh Chatham Memorial Hospital strives to provide quality care to patients. If you feel that there is a problem with any aspect of your care, please feel free to discuss the matter with a member of our staff. Our staff members will attempt to resolve the concern to your satisfaction through our Concerns Tracking Process. If you feel the problem has not been resolved, you have a right to file a direct grievance. Grievances may be filed in writing or verbally, and may be filed directly with:
Chief Executive Officer
Hugh Chatham Memorial Hospital
180 Parkwood Drive
Elkin, North Carolina 28621
All grievances filed will be reviewed promptly. You can expect a response within thirty (30) days of filing the grievance.
Written responses to grievances will include:
• A written notice of the decision of the
hospital, following review;
• The name of the hospital contact person;
• The steps taken on behalf of the patient to
investigate the grievance;
• The results of the grievance process; and
• The date of completion.
In the event that you are dissatisfied with our attempt to resolve a matter regarding the quality of care provided or premature discharge, you may notify the Peer Review Organization for North Carolina at any time.
Medical Review of North Carolina
P.O. Box 37309
Raleigh, North Carolina 27627
Hugh Chatham Memorial Hospital
Notice of Health Information Practices
This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
At Hugh Chatham Memorial Hospital, we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 1, 2003, and applies to all protected health information as defined by federal regulations.
Understanding Your Health Record/Information
Each time you visit Hugh Chatham Memorial Hospital; a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
• Basis for planning your care and treatment,
• Means of communication among the many health professionals who contribute to
• Legal document describing the care you received,
• Means by which you or a third-party payer can verify that services billed were
• A tool in educating health professionals,
• A source of data for medical research,
• A source of information for public health officials charged with improving the
health of this state and the nation,
• A source of data for our planning and marketing,
• A tool with which we can assess and continually work to improve the care we render
and the outcomes we achieve,
Your Health Information Rights
Your health record is the physical property of Hugh Chatham Memorial Hospital and you may not remove it. However, the information belongs to you and you have the right to:
• Obtain a paper copy of this notice of information practices upon request,
• Inspect and copy your health record.
• Amend your health record.
• Obtain an accounting of disclosures of your health information according to
• Request a restriction on certain uses and disclosures of ;your information and
• Revoke your authorization to use or disclose health information except to the extent
that action has already been taken.
Hugh Chatham Memorial Hospital is required to:
• Maintain the privacy of your health information,
• Provide you with this notice as to our legal duties and privacy practices with respect
to information we collect and maintain about you,
• Abide by the terms of this notice,
• Notify you if we are unable to agree to a requested restriction, and
• Accommodate reasonable requests you may have to communicate health
information by alternative means or at alternative locations.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you've supplied us.
We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
For More Information or to Report a Problem
If you have questions and would like additional information, you may contact the practice’s Privacy Officer, Lee Powe, CIO at (336) 527-7376.
If you believe your privacy rights have been violated, you can file a complaint with the Hospital’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for civil Rights. The address for the OCR is listed below:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
• We will use your health information for treatment.
• We will use your health information for payment.
• We will use your health information for regular health operations.
Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and except for religious affiliation, to other people who ask for you by name.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your health information.
Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be interest to you.
Fund raising: We may contact you as part of a fund-raising effort.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Correctional institution: Should you be an inmate of a correctional institution,
we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.
Patient Satisfaction: we may disclose health information to Press Ganey for the purpose of determining the level of patient satisfaction.
North Carolina Central Registry: We may disclose health information as required by Senate Bill 273 to collect diagnosis and treatment information on all cancer patients. The North Carolina Center Registry might contract individuals about participating in research studies.
Department of Vital Statistics: We may disclose health information as required for birth and death reporting. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
The Joint Comission has been accrediting hospitals for more than 50 years. Its accreditation is a nationwide seal of approval that indicates a hospital meets high performance standards.
Hugh Chatham Memorial Hospital Laboratory and Yadkin Valley Home Health are accredited by The Joint Commission. If any person has a concern about patient care and safety that the organization has not addressed, we encourage telephone follow up with our hospital's management by calling our administrative office at 336-527-7381. Should a concern not be resolved, the individual may contact the Joint Commission at 1-800-994-6610 or email firstname.lastname@example.org.
Visit the Joint Commission web site at www.jcaho.org.
El hospital commemorativo de Hugh Chatham y la salud casera del valle de Yadkin son acreditados por Joint Commission en la acreditación de las organizaciones de Healthcare. Si cualquier persona tiene una preocupación por cuidado y seguridad pacientes que la organización no ha tratado, animamos la continuación del teléfono con la gerencia de nuestro hospital llamando nuestra oficina administrativa en 336-527-7381. Si una preocupación no se resuelve, el individuo puede entrar en contacto con a la Comisión común en 1-800-994-6610 o email email@example.com.
Visite el Web site común de la Comisión en www.jcaho.org.