Designated Smoking Areas

1. 1. To prevent smoke from entering the building, smoking must occur at least fifteen (15) feet away from any entry door. “No smoking” signage will be posted at all entrances to the hospital in accordance with Ohio law.
   2. Smoking is not prohibited within fifty-feet (50) of any gas storage tanks, liquid oxygen tanks, compressors, or air intake equipment.

• Due to the safety concern of an open flame near any fuel or oxygen tanks, individuals may not light up a cigarette, etc. until reaching a designated smoking area.

1. Metal containers with lids for ash disposal are located in designated smoking areas.
2. Designated smoking areas will be clearly marked.
3. The use of tobacco products are permitted in the following designated areas:
   1. Marietta Memorial Hospital:
      1. areas with picnic tables and benches on the west side of the building
      2. outside the emergency department
      3. emergency department parking lot
   2. Selby General Hospital:
      1. Wooden deck area outside of the ground floor
   3. Off-Site Locations:
      1. Belpre behind the building near the dumpster (dumpster located outside of the buildings 799, 805, 807)
      2. Broughton building behind the building at the end of the wrap-around parking lot near the dumpster
      3. Reno building main parking lot entrance, right side of parking lot, smoking hut
      4. Wayne Street locations – picnic tables located behind 802 and 799 buildings.
      5. All other off-site locations vary but will have designated smoking areas clearly marked.

Visitors

1. 1. Any employee that observes a patient or visitor smoking in an undesignated are will immediate and in a courteous manner explain that smoking in not permitted in non-designated areas. The individual will be directed to the nearest smoking area.
   2. Any visitor who repeatedly violates the hospital smoking policy will be asked to leave the premises.

• In instances where the patient/visitor persist with violations of smoking in undesignated area, any employee is to direct this issue through their proper chain of command. Security may also be contacted in these circumstances.

Patients

1. At the time admission, any patient identified as a tobacco product user will be informed of the hospital smoking policy and offered a nicotine replacement based upon a physician order.
2. If the patient declines a nicotine replacement and requests to leave the unit to go outside to smoke, the patient will be required to sign an Against Medical Advice (AMA) form stating that they understand they are leaving the unit to smoke against the advice of the medical staff.

• Hospital staff is not required to accompany the patient outside to smoke; it is recommend that if the patient has a visitor that they accompany the patient as indicated.

1. The patient should be educated that they will be requested to notify the nursing staff on the unit prior to leaving the unit to smoke and upon their return.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care-like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency Services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as co payments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to balanced for these post-stabilization services.

Certain Services at an In-Network Hospital or Ambulatory Surgical Center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the co payments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Per Ohio House Bill 388, effective January 1, 2022, and as enacted in sections 3902.50, 3902.51, 3902.52, 3902.53, and 3902.54 of the Ohio Revised Code, Ohio has implemented balance billing provisions to protect consumers from “surprise billing” that can result from when consumers see a provider or receive services at a health care facility that is not in their health insurance plan’s network. Ohio’s provisions provide the same protections as the Federal provisions with exception of the following:

• Ohio’s provisions apply only to consumers covered by health insurance.
• Ohio’s provisions also apply to ground transport ambulance.

If you believe you’ve been wrongly billed and you are a consumer in Ohio, you may contact the Ohio Department of Insurance. Call 1 (800) 686-1526 or visit insurance.ohio.gov for more information about your rights under federal and/or state law.

If you believe you’ve been wrongly billed and you are a consumer in West Virginia, you may contact the West Virginia Offices of the Insurance Commissioner. Call 1 (888) 879-9842 or visit wvinsurance.gov for more information about your rights under federal law.

• Download this “No Surprise Act” Poster (pdf)

Effective: December 1st, 2024

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.

Memorial Health System, which is comprised of Marietta Memorial Hospital, Selby General Hospital and Sistersville General Hospital and their respective clinics, uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of Memorial Health System.

How We May Use and Disclose Medical Information About You

For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, or others who need to know about you to provide quality patient care. This information may be disclosed through information we record in your medical record or verbally between health care providers. We will also provide other medical facilities with information about you and your diagnoses which they will need in order to treat you.

For Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to give your insurance company information about a procedure we performed so we can be paid for the procedure.

For Health Care Operations: We may use and disclose medical information about you for operational purposes. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to evaluate the performance of our staff, assess the quality of care, and learn how to improve our facility and services.

Appointments. We may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund Raising. Memorial Health Foundation may use your information to contact you to raise funds for Memorial Health System and its health-related activities. We would only release contact information such as your name, address and phone number and the dates you received treatment or services at the hospital. If you do not want the Foundation to contact you for fundraising efforts, you must notify the Memorial Health Foundation Office.

Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (undetermined, good, fair, serious, critical) and your religious affiliation. However, you are entitled to opt out of the hospital directory, and your presence will not be shared except when required by law. Please inform a staff member if you would like to opt out of the directory and to discuss what this entails. Signing this form otherwise acknowledges your current wishes to opt-in to the hospital directory. You may decide to opt-in or out at any time upon request.

Special Situations in Which Your Information May be Released

(including in response to Federal State or Local Law)

• for judicial administrative proceedings pursuant to legal authority;
• to report information related to victims of abuse, neglect or domestic violence and to assist law enforcement officials in their law enforcement duties;
• if necessary to reduce or prevent a serious threat to your health or safety or the health or safety of another person or the public.
• in response to appropriate military authorities if you are a member of the military (including veterans)

Local Public Health Authorities

• in reporting child or elder abuse and neglect
• in reporting communicable diseases or your potential exposure to such
• in notifying you of recalls of drugs, products or devices you may be using

Deceased Patients

• to a medical examiner or coroner to identify a deceased individual or to identify the cause of death
• to allow funeral directors to do their jobs.

Organ/Tissue donation. Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes.

Workers’ Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.

We Will Always Get Your Written Authorization Before Releasing or Using Your Information:

• for marketing purposes
• in a manner that would constitute the sale of your protected health information
• in a manner not described in this notice and where required by either Federal or State Law.

Your Health Information Rights

You have a right to:

• request a restriction on certain uses and disclosures of your information as provided by 45 CFR §164.522. This may include a limit on medical information we disclose about you to someone who is involved in your care or payment for your care, such as a family member or friend. We are, however, not required to agree to a requested restriction except in cases where you have paid your bill in full and requested a restriction on releasing your information to a group health plan, insurer, or other payor for purposes of payment or health care operations. You may request a restriction by completing a form developed by the hospital, or you can send a written request to our Medical Records Department.
• obtain a paper copy of this notice at any time from the Registration Departments at Memorial Health System.
• amend your health record as provided in 45 CFR §164.526. To request a copy or to amend your information you must make your request in writing to the Medical Records Department.
• request communications of your health information by alternative means or at alternative locations.
• revoke special authorizations to use or disclose health information for certain purposes except to the extent that action has already been taken.
• request an accounting of all disclosures of your health information when the disclosure has not been pursuant to treatment, payment, operations, or an authorization and, if your information is maintained in an electronic format, request an accounting of any disclosures dating back three years from the date of the request.
• inspect or receive a hard copy or an electronic copy of your medical information in a format requested by you if such format is readily producible.
• receive a written notification of any inappropriate release or use of your protected health information.

Obligations of Memorial Health System

We are required to:

• maintain the privacy of protected health information.
• provide you with this notice of our legal duties and privacy practices with respect to your health information.
• abide by the terms of this notice.
• notify you of certain breaches or the inappropriate use or release of your information.
• notify you if we are unable to agree to a requested restriction on how your information is to be used or disclosed.
• accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations.
• release the minimum amount of your information necessary to accomplish information related functions and de-identify your information to the extent practicable.
• obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.
• not use or disclose your protected health information in any manner or for any purpose prohibited by HIPAA’s Reproductive Health Care Policy Rule at 45 CFR 164.502(a).

Changes to This Notice

We reserve the right to change our information practices and to make new provisions effective for all protected health information we maintain. At the end of this notice, you will be asked to sign that you have received the notice and have had the opportunity to receive a copy. Your signature is requested to help us determine which version of the notice you have received. Revised notices will be posted in the Registration Areas, Outpatient Center, Billing Office and our Web Site and a paper copy will be made available to you upon request.

If you have questions or complaints, please contact:

Memorial health System
Service Improvement Coordinator
401 Matthew Street
Marietta, Ohio 45750
(740) 374-1541

If you believe your privacy rights have been violated, you can file a complaint with the Memorial Health System Service Improvement Coordinator or with the Department of Health and Human Services. There will be no retaliation for filing a complaint.

Download

• Download “Memorial Health System Notice of Privacy Practices” Form

NONDISCRIMINATION STATEMENT

Memorial Health System complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, or gender identity and transgender.

LANGUAGE AND HEARING IMPAIRED

ATTENTION: If you speak Spanish or Chinese, or have a disability that impairs your ability to communicate effectively, language assistance services, free of charge, are available to you. Please call (740) 374-1436. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (740) 374-1436. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務請致電 (740) 374-1436.

ASSIGNMENT OF INSURANCE AND BENEFIT RIGHTS

In the event the undersigned is entitled to medical benefits, of any type whatsoever, arising out of any policy of insurance which insures patient or any other party liable to patient, the rights and benefits of such policy are hereby assigned to Memorial Health System (“MHS”) as the undersigned’s duly authorized representative for: i) application on patient’s bill and receipt of full payment under the policy; ii) initiation, pursuit, and prosecution of administrative appeal remedies and all other legal and equitable remedies with any said insurers or providers of medical benefits; and iii) obtaining a copy of the insuring agreement, governing plan, summary document, and settlement of information; and iv) obtaining a copy of any necessary medical information from providers. Additionally, this assignment is effective for application where the patient may be eligible for reimbursement for certain medications or devices through the medication or device manufacturer. The undersigned authorizes the use of the signature below on all insurances and/or employee health benefits claims and appeal submissions, and for medication/device manufacturer reimbursement applications. The patient and/or undersigned understand and agree that MHS may or may not pursue any policy of insurance or medication/device manufacturer reimbursement, within its sole discretion resulting in patient and/or undersigned’s responsibility for all or some of the charges. A copy of this assignment is to be considered as valid as the original.

FINANCIAL AGREEMENT AND PAYMENT GUARANTEE

The patient and/or undersigned agree that in consideration of the service to be rendered to the patient, they hereby jointly and individually obligate themselves to pay the charges incurred in accordance with the rates and terms of MHS. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney fees and collection expenses. All delinquent accounts bear interest at the legal rate. Additionally, the patient and/or undersigned agree, in order for MHS to collect amounts owed, we may contact you using pre-recorded/artificial voice and electronic messages by: i) telephone, including wireless telephone numbers, ii) text messages, and iii) e-mail, which could result in charges to you.

NON-EMPLOYED PRACTITIONERS

The patient and/or undersigned understands that he/she may be referred to and receive services from physicians or other health care practitioners who are not MHS employees or agents. This includes Pathologists, Radiologists, or other professionals or suppliers of services. MHS is not responsible for the acts or omissions of these non-employed practitioners who are not directed or controlled by MHS.

CONSENT TO TREAT

I hereby authorize MHS, its employees, agents, and representatives to perform general treatment resulting from evaluations connected to office visits. By signing below, I give consent to MHS providers and/or such assistants to provide me with medical treatment on current and future appointments.

PRESCRIPTION HISTORY REQUEST

I hereby authorize MHS to obtain my prescription history electronically.

ELECTRONIC PHOTO FOR REGISTRATION AND IDENTIFICATION

I hereby authorize MHS to obtain and use my electronic photo for MHS registration and identification purposes.

HEALTH INFORMATION EXCHANGE

MHS participates in one or more Health Information Exchanges. Healthcare providers can use these electronic networks to securely provide access to your health records so your providers have an accurate understanding of your health needs. I hereby authorize MHS to allow access to my health information through the Health Information Exchange for treatment and other health care operations. I understand that I may opt-out at any time by notifying the MHS Information Management Services/Medical Records Department.

SERVICE NOTIFICATIONS, SURVEYS AND COLLECTION OF AMOUNTS OWED

The patient and/or undersigned agree, in order for MHS to communicate with you regarding service notifications, surveys, and collections of amounts owed, we may contact you using pre-recorded/artificial voice and electronic messages by: (i) telephone, including wireless telephone numbers; (ii) text messages; and (iii) e-mail, which could result in charges to you. You may notify us anytime that you do not wish to be contacted in this manner and we will respect your choice.

GOVERNING LAW

This Agreement shall be governed by, and interpreted in accordance with, the internal laws of the State of Ohio. Washington County, Ohio, shall be the sole and exclusive venue for any litigation as between the parties that may be brought under, or arise out of, this Agreement.

AUTHORIZATION TO DISCUSS MEDICAL RECORDS

I authorize MHS to discuss my medical issues with the individual(s) listed below if I am not available. This authorization is in effect until revoked by me.

Download

• Download “Conditions of Treatment” Form

1. Nondiscrimination Statement: Memorial Health System complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, or gender identity and transgender.

2. Language and Hearing Impaired Assistance: ATTENTION: If you speak Spanish or Chinese, or have a disability that impairs your ability to communicate effectively, language assistance services, free of charge, are available to you. Call (740) 374-1436. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a (740) 374-1436. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 (740) 374-1436.

3. Physicians are Independent Contractors: The patient is under the control, direction, and treatment of his or her attending physician. The undersigned understands that he/she may require the service of physicians or groups of physicians who are not Hospital agents or employees, including Pathologist(s) and Radiologist(s) or other professional(s) or supplier(s) of services. The Hospital is not responsible for the acts or omissions of physicians that are not directed or controlled by the Hospital.

4. Medical and Surgical Consent: The undersigned consents to any imaging examination (including X-ray, MRI, CT), laboratory procedures, medications, infusions, transfusions of blood or blood products, anesthesia, medical or surgical treatment, general nursing care and/or other services rendered to the patient by members of the medical or allied health staff and Hospital employees under the instructions of treating physicians, physician assistants, and nurse practitioners.

5. Electronic Information Consent: The undersigned consents to the access, downloading and use of electronic health information, including electronic prescription information, for treatment and payment purposes; and the taking and use of the undersigned’s electronic photo solely for Hospital registration and identification purposes.

6. Health Information Exchange: MHS participates in one or more Health Information Exchanges. Healthcare providers can use these electronic networks to securely provide access to your health records so your providers have an accurate understanding of your health needs. I hereby authorize MHS to allow access to my health information through the Health Information Exchange for treatment and other health care operations. I understand that I may opt-out at any time by notifying the MHS Information Management Services/Medical Records Department.

7. Personal Belongings: It is understood and agreed that the Hospital maintains a safe for money and valuables, and the Hospital will not be liable for the loss or damage to any money or property of the patient unless placed in the safe.

8. Access to Patient Room and Other Areas of the Hospital. It is understood and agreed that the Hospital has the right to control access to patient rooms, to confiscate any illegal or unauthorized drugs, weapons, or other contraband that may be found, and to conduct electronic and other surveillance in all areas of the Hospital, including but not limited to patient rooms, for purposes of security, patient care, quality improvement, peer review, and other Hospital needs.

9. Financial Agreement and Payment Guarantee. The patient and/or undersigned agree that in consideration of the services to be rendered to the patient, they hereby jointly and individually obligate themselves to pay the charges incurred in accordance with the rates and terms of the Hospital. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney fees and collection expenses. All delinquent accounts bear interest at the legal rate.

10. Service Notifications, Surveys and Collection of Amounts Owed. The patient and/or undersigned agree, in order for the hospital to communicate with you regarding service notifications, surveys and collections of amounts owed, we may contact you using pre-recorded/artificial voice and electronic messages by: (i) telephone, including wireless telephone numbers; (ii) text messages; and (iii) e-mail, which could result in charges to you. You may notify us any time that you do not wish to be contacted in this manner and we will respect your choice.

11. Assignment of Insurance and Benefit Rights: In the event the undersigned is entitled to Hospital medical benefits, of any type whatsoever, arising out of any policy of insurance which insures patient or any other party liable to patient, the rights and benefits of such policy are hereby assigned to the Hospital as the undersigned’s duly authorized representative for: i) application on patient’s bill and receipt of full payment under the policy; ii) initiation, pursuit, and prosecution of administrative appeal remedies and all other legal and equitable remedies with any said insurers or providers of Hospital benefits; and iii) obtaining a copy of the insuring agreement, governing plan, summary document, and settlement information; and iv) obtaining a copy of any necessary medical information from providers. Additionally, this assignment is effective for applications where the patient may be eligible for reimbursement for certain medications or devices through the medication or device manufacturer. The undersigned authorizes the use of the signature below on all insurance and/or employee health benefits claims and appeal submissions, and for medication/device manufacturer reimbursement applications. The patient and/or undersigned understand and agree that Hospital may or may not pursue any policy of insurance or medication/device manufacturer reimbursement, within its sole discretion resulting in patient and/or undersigned’s responsibility for all or some of the charges. A photocopy of this assignment is to be considered as valid as the original.

12. Tissue Disposal: The undersigned consents to the disposal of any body tissues or parts which may be removed.

13. Nursing Care: This Hospital provides only general-duty nursing care unless, upon orders of the patient’s physician, physician assistant, or nurse practitioner, the patient is provided more intensive nursing care. If the patient requires the service of a special-duty nurse, it is agreed that those services must be arranged by the patient and/or the undersigned. The Hospital shall not be responsible for the failure to provide the same and is hereby released from liability arising from the fact that the patient receives no such additional care.

14. Consent to Personal Jurisdiction: The undersigned and/or patient expressly agrees that jurisdiction and venue for any lawsuit, proceeding or other action related to any medical, legal, equitable, or other claim or dispute arising out of items, and/or services furnished to the patient by, or at the request of the Hospital, its physicians, contractors and employees, shall be exclusively in a court located in Washington County Ohio where services are rendered. The undersigned and/or patient consents to the transfer and removal of any claim or action brought by patient against Hospital and/or person furnishing services to the patient, to a court in Washington County Ohio. The undersigned and/or patient expressly agrees to the application of Ohio law in any legal action brought on his/her behalf.

• Download “Conditions of Admission”

How it Works

Our new technology uses biometric identification to verify your identity through your fingerprint. It’s harmless and stores the data pattern, not the actual fingerprint, connecting it to your medical record. It will be used at future visits to speed up your check-in process and protect your identity. It can be used on any patient five years of age or older.

Patient Benefits

• Once enrolled, registration will be much quicker at your next visit
• Increases patient safety, allowing secure access to your unique medical record and medical history
• Helps ensure privacy at time of registration
• Helps protect from identity and medical theft

Safeguarding Your Information

Memorial Health System is a leader in health information technology. We are an early adopter of fingerprint authentication, joining several health systems across the country dedicated to protecting your identity. We are proud to partner with CrossChx to offer this innovative technology that protects our patients’ identities and keeps them safe.

If you have any questions or concerns about patient care, safety in the hospital, or billing, we encourage you to contact Marietta Memorial Hospital’s Service Improvement Coordinator at (740) 374-1541 or Selby General Hospital’s Service Improvement Coordinator at (740) 568-2040. As part of our management team, our service improvement coordinators will work with you to help resolve your concerns.

If your concerns cannot be resolved through the hospital, you may contact the Ohio Department of Health at (800) 669-3534 (Healthcare Facility Complaint Hotline).

Memorial Health System complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

Memorial Health System does not exclude people or treat them differently because of race, color, national origin, age, disability, gender identity, transgender or sex.

Memorial Health System provides free aids and services to people with disabilities to communicate effectively with us, such as

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English

If you need these services, contact the Nursing Supervisor at (740) 374-1436.

If you believe that Memorial Health System has failed to provide these services or discriminated based on race, color, national origin, age, disability, gender identity, transgender, or sex, you can file a grievance with:

Service Improvement Coordinator
Memorial Health System
(740) 374-3072 or (740) 236-7035
grievance@mhsystem.org

If you need assistance filing a grievance, the Service Improvement Coordinator can assist you. A grievance can be filed in person, by mail, fax, phone, or email. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/orc/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building
Washington, D.C. 20201
(800) 368-1019, (800) 537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/orc/office/file/index.htm

• Download “Non-Discrimination Notice to Our Patients” Form

Patient Self Determination: The right of competent adults to make their own medical treatment decisions, including the right to complete advance directives that indicate how and/or by whom decisions should be made in the event that the person becomes incapacitated and unable to make his or her own decision.

Advance Directive: A written statement of instructions – either a Living Will or Durable Power of Attorney for Health Care in Ohio – which designates a patient’s wishes in the event of incapacity.

Living Will: A legal document, which specifies the kinds of lifesaving and life-sustaining care a person does or does not want in the event of a terminal illness or a permanently unconscious state.

Durable Power of Attorney for Health Care: A legal document giving an individual the power to make healthcare decisions for another when he or she is unable to do so.

Terminal Condition: An incurable condition caused by injury, disease, or illness which – in the judgment of the attending physician and a second physician – would result in death within a short time.

Permanently Unconscious State: A state of permanent unconsciousness shown by

• A lack of awareness of self and the environment.
• The patient having no capacity to experience pain or suffering. Two physicians must certify this state exists.

Life-Sustaining Treatments: Any medical procedure, treatment, or other measure that, when administered, will serve mostly to prolong the process of dying.

Artificial Nutrition and Hydration: Food or fluid given through a tube in the nose or stomach, or an intravenous infusion.

Cardiopulmonary Resuscitation (CPR): Chest compressions, drugs, electrical shocks, and artificial breathing used to revive a patient.

Patient Rights within Memorial Health System

Making decisions about health care while in a crisis or leaving those decisions to others can be a difficult situation. As a competent adult, you have the right to make decisions about your own health care.

It is possible to give directions about your health care through one of two documents called “Advance Directives.” These documents – a Living Will and Durable Power of Attorney for Health Care – tell your physician and family what health care you would like to receive when you no longer can actively participate in those decisions.

The following information was prepared to help you understand more fully advance directives. At no time will your care be affected if you do not choose to prepare one. Copies of the Ohio Living Will and Durable Power of Attorney for Health Care are available should you choose to use one. Please ask the nursing staff if you would like someone with whom to discuss questions or concerns, and a hospital representative will see you.

Learn More

CaringInfo.org provides resources and information on making informed decisions about care and services. Topics include advance directives, palliative care, caregiving, and hospice care to help navigate serious or life-limiting illnesses with guides and other resources. 

• View or download Ohio Advance Directive Forms at CaringInfo.org. 
• View or download West Virginia Advance Directive Forms at CaringInfo.org. 

Financial Assistance

Financial assistance is available to the uninsured, underinsured, medically indigent, or financially needy individuals and families under our compassionate care program. Based on income guidelines, patients may qualify for up to 100% write-off of their charges. Please see the Financial Assistance web page to access the Financial Assistance Application and Policy, and the Billing and Collection Policy.

For those who don’t qualify for financial assistance based on current guidelines, other sources of financial assistance may be available, including extended payment plans or discounts for prompt payment of your account. Please contact the business office at (740) 374-1413 to discuss your specific needs. We are here to help.

Memorial Health System depends on prompt payment of bills to meet expenses and continue to provide quality healthcare services to the community.

Hospital Insurance

Memorial Health System will bill your healthcare insurance if you provide the complete information at the time of registration/admission. Please remember that you are ultimately responsible for the payment of all charges.

Pre-certification of insurance coverage is the responsibility of the patient. The authorization form you signed at the time of registration giving us permission to bill your insurance permits us to file your claim with all your healthcare insurance companies.

Patient’s Share of the Bill

Patients will not receive statements until all health insurance companies, which have been identified for the hospital, have been billed and benefits paid. If no response is received from your insurance within 45 days, we will look to the patient/guarantor for payment in full.

Payments for co-insurance, deductibles, or bills denied by your insurance are due upon receipt of your first statement.

Self-Pay (No Insurance)

For non-emergent admissions, you will be contacted by our pre-registration department a minimum of fourteen (14) days prior to the procedure. As part of our pre-registration process, patients will be notified of their financial responsibility. Patients who are unable to satisfy their responsibilities prior to admission are required to work with a Patient Financial Advocate to discuss other payment arrangements and the Financial Assistance programs available. Payment and/or secured financial application is required prior to the procedure.

Personal Injury Claim

Memorial Health System will provide an itemized statement to you upon request to enable you to complete a personal injury claim. Medical records information must be obtained through the Health Information Services department. Responsibility for payment in full remains with the patient/guarantor.

Insurance

Memorial Health System accepts the following insurance and contracted managed care plans.

Insurance and Contracted Health Plans

• Memorial Health System Plans

Are you a health plan provider and want information about enrolling your plans with Memorial Health System?

Contact Inge Chenoweth at (740) 568-5477.

Commonly Asked Questions

How do I get a copy of an itemized bill?

You may call the business office at (740) 374-1413 and an itemized bill will be sent to you.

Will Memorial Health System accept my insurance?

MHS accepts Medicare, Medicaid, and other major insurance carriers. Please contact your insurance company or employer for the specific requirements of your plan.

Will Memorial Health System bill my insurance company/companies

Yes, as a courtesy to you, MHS will send a claim to your insurance company/companies. If we do not receive payment within 45 days, we must look to you for payment of the bill. Your insurance policy is a contract between you and your insurance company. Communication with your insurance company is highly recommended.

Does Memorial Health System accept credit cards?

Yes. Visa, Mastercard, and Discover are accepted forms of payment. You may also pay by cash, check, or money order.

How can I check the status of my account?

If it has been at least 30 days since your date of service, contact your insurance carrier for claim status. After speaking with your insurance company, contact the business office at (740) 374-1413 if you have additional questions regarding the claim.

What should I do if my insurance company denies a claim?

If you feel the claim was denied in error, contact your insurance carrier for instructions on how to appeal their decision. The business office should also receive an explanation of benefits (EOB) from your insurance company stating the claim was denied. This information will be reflected on your account, and you will receive a statement requesting payment in full.

How will I know if my hospital bill has been paid?

Your insurance company should send you an explanation of benefits (EOB) indicating they have processed the claim. The EOB will show any payments made to the hospital and the amount that is your responsibility. You will receive a statement from the hospital once all insurances have been processed. This statement will reflect all insurance payments, adjustments, and the balance remaining. Any remaining balance is your responsibility.

What if I cannot pay my bill?

To set up payment arrangements on your healthcare bill, contact Help Financial at (800) 752-9613 immediately upon receipt of your statement. Call (740) 374-1413 to speak with the Patient Representative regarding MHS payment guidelines.

Financial  Assistance

We can work with you to secure financial assistance for your care.

Financial Assistance is available for qualified patients. It is important to let us know before you visit if you do not have health insurance or if you are unable to pay for your services in full so that we can help ensure you receive all the financial support for which you are qualified. All applications for financial assistance should be completed as soon as possible.

To apply for financial assistance, please complete a Financial Assistance Application and return it to us as directed on the form. The Plain Language Summary and the Financial Assistance Policy further explains the process, qualifications, and how to get additional information regarding financial assistance.

• See if you Qualify
• Financial Assistance Application
• Financial Assistance Summary
• Financial Assistance Policy

Memorial Health System offers trained financial counselors who can help determine if you might qualify for an assistance program. Our counselors are available by calling (740) 568-5263 from 8 a.m. to 4 p.m. or emailing financialassistance@mhsystem.org.

Financial assistance programs offered include:

Medicaid provides health coverage to millions of Americans, including children, pregnant women, parents, seniors, and individuals with disabilities. Each state sets individual eligibility criteria and requires patients to complete an application form. We will help qualified patients complete our application process at no additional charge.

Hospital Care Assurance Program (HCAP) provides free care to Ohio residents who are not receiving Medicaid benefits and whose income falls at or below the federal poverty guidelines. This program only covers hospital services that are deemed medically necessary by your physician. We will help qualified patients complete our application process at no additional charge. Please see the link above for access to the financial assistance application and policy.

Other financial assistance may be available to patients who are not residents of Ohio and/or whose income is above federal poverty guidelines. Please see the link above for access to the financial assistance application and policy.

Memorial Health System not-for-profit facilities have adopted billing and collection policies appropriate to their patients’ circumstances.

Open Door Policy

Memorial Health System has an open-door policy – no patients are denied admission because of their inability to pay for services. Also, federal and state regulations require that the hospital furnish free care to patients with income at or below the poverty level. Proof of income may be required. Please call our Financial Counselor at (740) 568-5263 between 8 a.m. – 4 p.m., Monday through Friday for more information.

Workers’ Compensation

The hospital will bill the patient until a valid claim number is obtained and given to Patient Accounts. The claim number enables us to bill Workers’ Compensation for your care. The patient will be billed if the claim is denied by Workers’ Compensation. Non-covered services will remain the responsibility of the patient unless personal health insurance information is provided to Patient Accounts.

If you have questions concerning a Workers’ Compensation claim, please email: wc@mhsystem.org.

Courtesy Discharge

Patients will be extended a courtesy discharge permitting them to leave the hospital without clearing through the Cashier’s Office if the following requirements are met:

• Insurance has been verified and all appropriate forms are signed
• Satisfactory financial arrangements have been made

The hospital accepts personal checks, Visa, MasterCard, and Discover as payment.

Point of Service Payment

Most people want to know the cost of their medical services, but do not know how to access the information. Knowing the cost of a service up front enables you to make informed decisions about your health and care. In recent years, hospitals have introduced programs to provide easier payment methods for patients. One program is called Point-of-Service Payment, and it consists of patients paying their portion of the bill at the time of service or immediately after services have been delivered.

Memorial Health System announced the implementation of a payment process that helps patients know and understand the cost of their medical care before receiving services in non-emergent situations. As part of its financial transparency to the community, the health system’s software tool offers real-time cost estimates for co-pay, co-insurance, and deductibles so patients can make informed decisions about their health care.

Q&A for Patients

Why has the hospital implemented this program? I was never asked to pay at the time of service before.

Today, most service organizations require payment at the time of service, including hospitals. This is done primarily for three reasons:

1. Providing patients’ information about their expected portion of the bill upfront allows them to make informed decisions.
2. A significant portion of a hospital’s revenue is from insured patients’ co-payments, deductibles, and non-covered procedures, as well as payments from patients without insurance.
3. By collecting payments at the Point-of-Service, hospital operating costs are kept down since collecting after patients leave the facility can be both costly and time-consuming. These savings are then reinvested to help operate the hospital and pay for new medical technology–all of which benefit our patients and community.

How can I pay my portion of the bill?

For your convenience, we take cash, checks, and credit cards (Visa, MasterCard, and Discover). Our representative can help you complete this process. We participate in many programs to assist our patients with their financial responsibility, including a discount of 15% pre- and at the time of service.

How does the hospital determine my payment?

For scheduled services, the hospital will call and verify insurance coverage in advance and notify the patient what their portion of the bill will be. In addition, many insurance plans list the co-pays for various services, such as emergency room visit co-pays, on the insurance card. The main difference between Point-of-Service and other payment programs is that we ask for your portion of the bill while you are at the hospital rather than billing you later.

For elective procedures, will I know my portion of the bill before I get to the hospital?

We will make every effort to contact your insurance company so that you will know the balance due at the time of service. We will ensure that pre-certification is obtained for you, which ensures that you have met the various criteria that insurance companies sometimes require for certain services before they will agree to pay. We do this on your behalf to help ensure your insurance company will not deny your claim, which could leave you responsible for the entire bill.

What if I am in a financially difficult situation?

We understand that sometimes paying deductibles or co-pays can be difficult due to life situations. If you need assistance with payment options, you will be referred to a representative who can help identify possible financial assistance such as Medicaid or any other federal, state, or local benefits coverage. The representative can also help develop a payment plan that is satisfactory to both the patient and the hospital. We participate in many programs to assist our patients in their financing including a prompt pay discount of 15%. This helps relieve the stress of worrying about bills at a time when you need to focus on getting well.

What if I come to the hospital in an emergency?

The first priority of any emergency room nurse or physician is to care for patients and do everything possible to help them during an emergency situation. With that in mind, after a medical screening examination has been performed and the patient is determined not to have an emergency medical condition, the registration clerk may ask for payment.

What do I need to bring with me to the hospital now?

To assist the hospital in determining the proper amount due at the point-of-service, patients should bring insurance cards, as well as their Social Security number and photo identification (such as a driver’s license). The registration clerk will use this information to confirm with your insurance provider what your co-payment and deductibles are for the services you are receiving. Patients should also be prepared to pay by bringing their checkbook, credit card, etc.

Provider-Based Billing

Provider-Based Billing for Medicare and Medicaid Patients

Thank you for being a valued patient at one of Memorial Health System’s employed (provider based) physician locations. These physician locations now function as departments of Memorial Health System.

What is Provider Based Billing (PBB)?

PBB refers to the billing process for services rendered in a hospital department or location. This process takes place when the hospital owns space and employs physicians and other support personnel who are involved in patient care.

Will there be a change in how patients receive care?

No. Patients will continue to receive excellent quality care with their physician, and scheduling appointments and tests will be handled as they always have been in the past. However, there is a change in how the hospital will bill your insurance carrier for these services.

How does this affect the billing process?

Because care is provided in a department of the hospital, patients will receive a bill from Memorial Health System as well as a separate bill for the professional services provided by their physician. This also includes physicians who interpret the results of diagnostic tests.

Medicare beneficiaries are responsible for the co-insurance amount on the services they receive. These amounts are determined by Medicare and are based on the services performed.

Will Medicare patients have to pay more for services?

Some Medicare patients may be covered by their supplemental insurance and will not have to pay more out-of-pocket, but Medicare patients without supplemental insurance may have to pay a small amount. Patients with other health insurance should check with their insurance provider and ask whether it covers facility charges or Provider Based Billing. Depending on specific insurance benefits, additional out-of-pocket expenses may be incurred by Provider-Based Billing.

Where can patients call for more information?

Contact a financial counselor at (740) 374-1413.

Understanding Your Statement

You will not receive a statement until your insurance company has considered your claim. The statement will reflect all hospital services you received during your treatment and will indicate any payment made by your insurance company, as well as any adjustment per the terms of your insurance contract. The amount of your self-pay balance will be shown in a box at the top of the statement, along with the date payment is due. (Please note that you may receive an itemized bill at any time by calling our business office at (740) 374-1413.)

You may receive statements from physicians that treated you as well as physicians that you did not see in person. These charges are for professional services (such as interpreting your test results). Pathologists, radiologists, cardiologists, anesthesiologists, and other specialists are required to submit separate bills to you. Should you have questions concerning the physician’s bill, please contact them directly. To assist you, we have listed the most frequently requested telephone numbers below.

• Marietta Imaging (Radiologist)
  (866) 863-6739
• MIC Billing (Pathologist)
  (800) 288-8325
• Marietta Healthcare Physicians
  (800) 727-5498
• Marietta Healthcare Systems
  (740) 374-1413

A Patient at Memorial Health System Has the Right To:

A. The right to participate in the development and implementation of his or her plan of care.

B. His or her 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, 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.

C. The right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives.

D. 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.

E. The right to personal privacy.

F. The right to receive care in a safe setting.

G. The right to be free from all forms of abuse or harassment.

H. The right to the confidentiality of his or her clinical records.

I. The right to access their medical records, including current medical records, upon an oral or written request, in the form and format requested by the individual if it is readily producible in such form and format (including an electronic form or format when such medical records are maintained electronically); or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, and within a reasonable time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits; 482.13(d)(2).

J. The right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff.

K. The right to be fully informed of and to consent or refuse to participate in any unusual, experimental, or research project without compromising his or her access to services.

L. The right to know the professional status of any person providing his or her care and/or services.

M. The right to know the reasons for any proposed change in the Professional Staff responsible for his or her care.

N. The right to know the reasons for his or her transfer either within or outside the hospital.

O. The relationship(s) of the hospital to other persons or organizations participating in the provision of his or her care.

P. The right of access to the cost, itemized when possible, of services rendered within a reasonable period of time.

Q. The right to be informed of the source of the hospital’s reimbursement for his or her services, and of any limitations which may be placed upon his or her care.

R. Informed of the right to have pain treated as effectively as possible.

S. A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reason for the clinical restriction or limitation. A hospital must meet the following requirements:

• Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section
• Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time
• Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability
• Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences

The patient’s family has the right of informed consent for donation of organs and tissues. Patients have the right to address their concerns about patient care and safety to the patient representative at (740) 374- 1541 and/or an ethics committee representative. If the patient does not wish to talk with the patient representative, or if the concern is unresolved by the patient representative, the patient may contact the hospital’s Chief Executive Officer. Patients have the right to contact the Ohio Department of Health at (800) 342-0553 or visit odh.ohio.gov; or the State Quality Improvement Agency (QIO), Livanta at (888) 524-9900 or visit www.livantaqio.com/en/states/ohio; or our accrediting organization, Healthcare Facilities Accreditation Program at (312) 920-7383 or visit achc.org

A Patient at Marietta Memorial Hospital and Selby General Hospital Has the Responsibility To:

• Provide, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other health-related matters
• Report unexpected changes in his or her condition to the responsible caregiver and/or physician
• Request information or additional clarification on his or her health status and proposed course of action as it relates to treatment
• Inform their physician and other caregivers if he/she anticipates problems in following prescribed treatment
• Communicate any pain that he or she is experiencing to the medical provider
• Take an active role in the safe delivery of their care
• Follow the treatment plan recommended by the physician primarily responsible for his or her care. This may include following the instructions of nurses and allied health personnel as they carry out the coordinated plan of care, implement the physician’s orders, and enforce the applicable hospital rules and regulations
• Keep appointments and notify the physician or hospital when unable to do so
• Be responsible for his or her actions if treatment is refused or if a physician’s instructions are not followed
• Ensure that the financial obligations of his or her health care are fulfilled as promptly as possible
• Follow MMH’s and SGH’s rules and regulations, including the smoking policy, the personal electrical devices policy, and the visitation policy
• Be considerate of the rights of other patients and hospital personnel, and for assisting in the control of noises, smoking, and the number of visitors
• Be respectful of the property of other people and of the hospital
• Patients and their families must report perceived risks in their care and unexpected changes in their condition

Language Access Resources

Memorial Health System complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Memorial Health System does not exclude people or treat them differently because of race, color, national origin, age, disability, gender identity, transgender, or sex. Memorial Health System provides free aids and services to people with disabilities to communicate effectively with us including:

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)

Memorial Health System also provides free language services to people whose primary language is not English. 

If you believe that Memorial Health System has failed to provide these services or discriminated based on race, color, national origin, age, disability, gender identity, transgender, or sex, you can file a grievance with:

Service Improvement Coordinator
Memorial Health System
(740) 374-1541
grievance@mhsystem.org

If you need assistance filing a grievance, the Service Improvement Coordinator can assist you. A grievance can be filed in person, by mail, fax, phone, or email. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/orc/smartscreen/main.jsf or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building
Washington, D.C. 20201
(800) 368-1019, (800) 537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/orc/office/file/index.html