Financial Policy / Responsibility

Please print out the Financial Policy form, complete it and fax back or bring to your appointment.


  • You have the right to access information contained in your medical record within a reasonable time frame and to have the information interpreted as necessary. You may, for a fee, obtain copies of your medical record.
  • You have the right to receive a “Notice of Privacy Practices” that describes how Village Health may use and disclose medical information about you and how you can get access to your information. You will be asked to acknowledge receiving the Notice in writing.
  • You have the right to request an amendment to your protected health information in our files if you believe that it is incorrect.
  • You have the right to receive an accounting of the disclosures of your protected health information that were required by public health regulations or legal mandate.
  • You have the right to request restrictions on certain information to carry out treatment, payment or health care operations functions or to prohibit such disclosure. We will consider your request, but are not required to agree to the request restrictions.
  • You have the right to receive confidential communications from us at an alternative address or phone number.
  • If being transferred to the hospital, you have the right to have a family member or representative of your choice and your own physician notified promptly of your transfer.
  • You have the right to exclude any or all family members from participating in your care decisions.
  • You have the right to be free from seclusion or restraints, of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff.
  • If it is determined to be necessary that you be transferred to another health care facility or hospital, you may expect that someone will explain why a transfer is recommended and any other choices available to you.
  • You may expect to be told when students or persons from outside the organization are involved in your care.
  • You do not have to take part in any research or experimental project.
  • If treated, you may expect to be told what to do to continue your care to help you recover after you leave.
  • You may ask about financial help available.
  • You have the right to file a formal grievance with Village Health, and the State of Michigan.
  • You have the right to not be discriminated against in your care on the basis of race, religion, color, national origin, sex, age, or handicap.


  • You are responsible for following the organization’s rules and regulations.
  • You are responsible for providing, to the best of your knowledge, a complete and accurate medical history.
  • You are responsible for making it known whether you understand the proposed course of action and what you are expected to do.
  • You are responsible for following the advice and instructions prescribed in a course of treatment by the physician.
  • You are responsible for your health if you refuse treatment or do not follow instructions.
  • You are responsible for telling your physician if there is an unexpected change in your condition or if problems arise in your treatment.
  • You are responsible for being considerate of the rights of other patients, personnel and property.
  • You are responsible for paying your bill promptly and telling us if you cannot pay the bill. If you are not paying your own bill, you are responsible for telling us who will be paying it.
  • You are responsible for making the proper organizational authorities aware, in a timely manner, of any problems encountered in your care and treatment.