As a consumer of home care and services you are entitled to receive notification of the following rights both orally and in writing. You have the right to exercise the following rights without retribution or retaliation from agency staff:   
  1. Receive written information concerning the agency’s policies on advance directives, including a description of applicable state law;
  2. Receive information about the care and services to be furnished, the disciplines that will furnish care, the frequency of proposed visits in advance and receive information about any changes in the care and services to be furnished; 
  3. Receive care and services from the agency without discrimination based upon personal, cultural or ethnic preference, disabilities or whether you have formulated an advance directive;
  4. Authorize a representative to exercise your rights as a consumer of home care;
  5. Be informed of the full name, licensure status, staff position and employer of all persons supplying, staffing or supervising the care and services you receive; 
  6. Be informed and participate in planning care and services and receive care and services from staff who are properly trained and competent to perform their duties;
  7. Refuse treatment within the confines of the law and be informed of the consequences of such action;
  8. Participate in experimental research only upon your voluntary written consent;
  9. Have you and your property to be treated with respect and be free from neglect, financial exploitation, verbal, physical and psychological abuse including humiliation, intimidation or punishment;
  10. Be free from involuntary confinement, and from physical or chemical restraints;
  11. Be ensured of the confidentiality of all of your records, communications, and personal information and to be informed of the agency's policies and procedures regarding disclosure of clinical information and records;
  12. Express complaints verbally or in writing about services or care that is or is not furnished, or about the lack of respect for your person or property by anyone who is furnishing services on behalf of the agency.

If you believe your rights have been violated you may contact the agency directly:

Galaxy Home Health, LLC

1330 S. Potomac St, STE 118 Aurora, CO  80012

Phone: 720-484-5770 Fax: 720-459-7550

Contact Person (responsible for complaint intake and problem resolution process)

Hari Timsina, Administrator

You may also file a complaint with the Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment via mail or telephone:

4300 Cherry Creek Drive South

Denver, CO 80246

303-692-2910 or 1-800-842-8826

I attest to verbal and written receipt of the aforementioned notice of rights:
MM slash DD slash YYYY
MM slash DD slash YYYY