Empowering Your Health Journey

You will be offered this notice before care at your first visit and asked to acknowledge receipt during registration. It is also available in the clinic, via QR code, and on our website. Please ask questions if anything is unclear.

Patient Rights Upheld by the Clinic

Connect Medical Clinic is committed to providing respectful care while meeting your needs. As a patient:

• You have the right to considerate, respectful care that protects your dignity.
• You will not be denied access to care due to race, creed, color, national origin, sex, age, sexual orientation, or disability.
• You have the right to personal privacy, confidential medical and personal records, and care in a safe environment.
• You have the right to be free from abuse and harassment, and from restraint or seclusion used for convenience, discipline, coercion, or retaliation.
• You have the right to free interpretation and language assistance services when needed.
• You have the right to know the names and professional titles of our Medical Director and healthcare professionals involved in your care.
• You have the right to request a change in provider when other qualified providers are available. Requests will be handled respectfully and without retaliation.
• You have the right to a prompt and reasonable response to requests for services within the clinic’s capacity and scope of services.
• You have the right to information about clinic rules and regulations that affect your care or conduct.
• You have the right to clear and timely cost information, including a Good Faith Estimate when required for uninsured or self-pay patients, or upon request as applicable.

Informed Decisions and Consent

• You have the right to participate in developing your plan of care and to involve a representative of your choice. Authority to make decisions on your behalf is determined according to law.
• You have the right to information about your diagnosis, proposed care, purpose, risks, benefits, and reasonable alternatives in a manner and language you understand. You may ask questions before deciding.
• You have the right to give or withhold informed consent before treatment or a procedure, refuse treatment as permitted by law, and be informed of the consequences of refusal.
• You may decline or withdraw consent, subject to applicable law, and discuss your choices about in-person or telehealth care; observers, chaperones, students, or trainees; referrals; and educational or support services.
• You may consent to or decline photographs, videos, testimonials, social media content, and other clinic media or communications activities requiring your permission.

Advance Directives

You have the right to have an advance directive consistent with applicable law. CMC does not implement advance directives on site. You may provide a copy for your medical record. Emergency services (911) will be contacted when indicated. If you want help creating a directive, we can refer you to outside resources, such as an attorney or hospital.

Patient Privacy Rights

You will receive our Notice of Privacy Practices at your first encounter and may request another copy at any time. Subject to applicable law, you may:

• Inspect your medical record and request a paper or electronic copy.*
• Authorize the release of your medical records to yourself, another individual or organization when an authorization is required. If you desire sharing to continue after that authorization expires, you may renew or replace it.
• Request an amendment to your medical record.
• Request confidential communications, including a different contact method or location.
• Request restrictions on use or sharing of your health information. We must honor a qualifying request not to disclose information about a service paid in full out of pocket to your health plan for payment or healthcare operations, unless disclosure is required by law.
• Request an accounting of certain disclosures of your health information.
• Learn about our participation in health information exchange, ask how your information is shared and protected, and request information about participation options, including opting out where applicable.
• File a privacy complaint with Connect Medical Clinic or the U.S. Department of Health and Human Services without retaliation.

To exercise these rights, request the relevant form or contact our Privacy Officer at 701-483-9353. Our Notice of Privacy Practices explains these rights and their limits.

Patient Responsibilities

To support safe and effective care, you are responsible for:

• Providing accurate and complete health information, including medical history, current and past health problems, allergies, and all medications, over-the-counter products, and supplements.
• Participating in care decisions and following the agreed-upon treatment plan to the extent you are able. Tell us about barriers to following your plan.
• Asking questions and telling the care team when you do not understand information or instructions.
• Reporting changes in your condition, symptoms, or pain to a care team member.
• Arranging transportation and a responsible adult to assist you when directed by your provider or discharge instructions.
• Accepting personal financial responsibility for charges not covered by insurance and asking questions about fees, payment expectations, or billing.
• Treating healthcare professionals, staff, other patients, and visitors respectfully and respecting the rights and property of others.
• Following clinic rules and regulations and keeping appointments or canceling in advance when possible.
• Communicating questions or concerns about how your health information is used or shared. You may ask staff to connect you with our Privacy Officer.

Questions, Concerns, and Grievances

You and your family may raise concerns, complaints, grievances, or suggestions without retaliation or an adverse effect on your care. Suggestion, Complaint, and Grievance forms are available at the front desk. Ask staff for assistance or information about the process.

You may discuss concerns with the healthcare professional on duty. If unresolved, contact Tara Zettel, CEO, at 701-483-9353. You may also contact the North Dakota Department of Health at 701-328-2372 or AAAHC at 847-853-6060. You do not have to complete the clinic’s internal process before contacting an outside agency.

*Connect Medical Clinic does not charge for routine patient requests to access or obtain copies of their own medical records. For large-volume requests requiring mailing, cost-based postage fees may apply case by case, consistent with HIPAA.

11.03.2026