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 Advance Health Care Directive (Living Will)
At your request, Queen's can provide you with an Advance Health Care Directive or Living Will. You may download the "Advance Health Care Directive" form (available in PDF below) to print out and complete. The form must be signed by you in the presence of two witnesses, or notarized. Notary services are available at Queen's Patient Relations department. If you have any questions about Advanced Directives or Living Wills, feel free to call Queen's Patient Relations department at 808.547.4602.
There is no charge for physicians and other health care facilities (for direct patient care) if sent directly to a physician or health care facility and requested by them. If a patient requests that information to be sent to the physician or health care facility at the direction of the health provider, it will first be verified before any records are sent.
All other requests are billed directly to the receiver of the medical records (e.g. attorneys, vocational rehabilitation, etc.). For personal and out-of-state requests, fees must be paid in advance.
Download the Advance Health Care Directive form
Reproduction of Medical Records
All requests for Medical Information must be made in writing to Queen's Medical Records Department, Release of Medical Information Section. (The Medical Records department does not have radiology films or billing records.)
You may download the "Authorization to Release Medical Information" form (available in PDF below) to print a hard copy and then complete. All requests for Medical Information must be accompanied by this form and signed by the patient, legal guardian or next of kin.
Mail completed and signed authorization form to:
The Queen's Medical Center
Medical Records Department
1301 Punchbowl Street
Honolulu, HI 96813
The completed form may also be Faxed to 808.537.7806. If you have any questions, please call The Queen's Medical Records department, Release of Medical Information Section, during regular business hours, Monday through Friday, 8:00 am to 4:30 pm.
Download the Authorization to Release Medical Information form
Duplication Fees
Patient Request (Payment required for personal use)
Charges for copies:
- $.25 per page for hard copies
- $.50 Per page for records that are on microfilm
There is no charge for physicians and other health care facilities (for direct patient care) if sent directly to a physician or health care facility and requested by them. If a patient requests that information to be sent to the physician or health care facility at the direction of the health provider, it will first be verified before any records are sent.
All other requests are billed directly to the receiver of the medical records (e.g. attorneys, vocational rehabilitation, etc.). For personal and out-of-state requests, fees must be paid in advance.
Patient Responsibilities
1. The patient has the responsibility to participate in his/her own health care decisions, and to obtain necessary information from his/her doctor to make informed choices.
2. The patient has the responsibility to be as accurate and complete as possible when providing medical history and treatment information. It is the responsibility of the patient, family or designated representative to ensure that a current copy of the patient's Advance Health Care Directive is provided to the Medical Center, should the patient have one. The patient and family are responsible for reporting perceived risks in their care and unexpected changes in the patient's condition.
3. The patient has the responsibility to inform his/her doctor or nurse if he/she has questions or concerns regarding treatment. The patient has the responsibility to follow his/her doctor's advice regarding health care requirements. The patient is responsible for notifying his/her doctor or other health care providers if the designated treatment plan cannot be followed.
4. The patient, his/her family, and friends have the responsibility to follow the Medical Center's rules and regulations, including smoking policies, being considerate of other patient's privacy, controlling the noise level, and the number of visitors. The carrying of weapons, or the use of alcohol or drugs not prescribed by a doctor, will not be permitted.
5. The patient, his/her family, and friends have the responsibility to behave considerately and appropriately with Medical Center personnel. If a patient is verbally or physically disruptive, they may be referred elsewhere for care and the Medical Center may refuse further treatment, except in an emergency as required by law.
6. The patient has the responsibility to cooperate with the Medical Center by providing complete, timely insurance information and making payment arrangements on any balances.
Patient Rights
The Queen's Medical Center encourages patients to exercise their rights. If you need help in understanding your rights and responsibilities, or you require interpreters or assistive devices, please call Queen's Patient Relations department at 808.547.4602.
1. Selection of Doctor
The patient has the right to select his/her doctor. This doctor shall recommend and manage the treatment and care of the patient, including hospitalization, or the use of hospital services. The doctor or doctors providing care to the patient, including radiologists, pathologists, anesthesiologists, radiation oncologists and emergency department doctors are independent doctors and not employees or agents of The Queen's Medical Center (Medical Center) unless the patient is expressly informed otherwise.
2. Teaching Facility
The Medical Center is a teaching facility and the training of residents, students and other health care professionals are integral to the Medical Center's mission. Except in emergency situations, patients have a right to request that residents and students not be involved in their care. It is not always possible to honor such requests, but the Medical Center will try to do so to the extent that such restriction will not impact the patient's treatment.
3. Respectful Care and Patient Safety
The patient has the right to considerate and respectful care. The patient has the right to be treated in a safe and secure setting, free from discrimination, abuse or threat.
4. Information About Treatment
The patient has the right to be informed by his/her doctor of his/her diagnosis, treatment, prognosis, and proposed procedures, including the risks involved, in terms that they understand. The patient has the right to know the names and roles of persons treating him/her. The patient or his/her authorized representative has the right to obtain information from his/her medical record within a reasonable time frame, within the limits of the law.
5. Participation in Care Planning
The patient has the right to make informed decisions regarding his/her care, to be told of his/her health status and to be part of care planning and treatment. The patient has the right to decide if family members will participate in his/her care. The patient has the right to refuse treatment and conditions of care, including withholding resuscitative measures, forgoing or withdrawal of life sustaining treatment in accordance with applicable law and regulations. The patient has the right to be involved in post-discharge decisions and to be told of any services in which the Medical Center has an interest. Should the patient refuse the recommended treatment plan, conditions of care or discharge plans, alternatives will be discussed with the patient in accordance with the Medical Center's policies and procedures.
6. Right to Treatment
The patient has the right to access care as long as that care is within the Medical Center's capacity, mission, and policies. When the Medical Center cannot provide the care or is no longer the appropriate setting for the patient, the staff will fully inform the patient of other choices for care. If it is appropriate and medically advisable, the Medical Center may transfer the patient to another facility as long as the transfer is accepted by the receiving facility.
7. Informed Consent
Except in emergency situations, the patient has the right to receive information from his/her doctor regarding the benefits, risks and alternatives of any procedure or treatment recommended by the doctor which requires consent.
8. Research
The patient has the right to consent to or refuse to participate in proposed research studies affecting care and treatment and to have those studies fully explained prior to consent. Any refusal to participate will not compromise a patient's access to other Medical Center services.
9. Advanced Health Care Directives
The patient has the right to have an Advance Health Care Directive which allows the patient to specify his/her health care wishes. The patient also has the right to name a person who would make health care decisions for the patient if he/she is unable to do so, to the extent permitted by law and Medical Center policy.
10. Ethical Issues/Care at the End of Life
The patient has the right to be involved in ethical questions that arise in the course of his/her care or any issues dealing with care at the end of life. Concerns for the patient's comfort and dignity will guide all aspects of care with respect to his/her personal values and beliefs. If a patient or family would like to call an Ethics Committee member for help, please contact 538-9011.
11. Pain Management
The patient has the right to have appropriate assessment and management of pain when admitted to the Medical Center and throughout his/her hospitalization. The Medical Center plans, supports, and coordinates activities and resources to ensure that every patient's pain is recognized and addressed.
12. Privacy and Confidentiality
Within the limits of the law, patients have the right to privacy and confidentiality about their health care, whether as an inpatient or outpatient, and the right to be provided with a copy of the Medical Center's Notice of Privacy Practices. Case discussion, consultation, examination, and treatment will be conducted to protect each patient's privacy and confidentiality to the extent reasonably possible.
13. Concerns and Complaints
The patient has the right to receive a written statement of his/her rights. The patient has a right to make a complaint without compromising future access to care. Complaints will be handled in a timely manner. Should the resolution be unacceptable to the complainant, the complainant may request to have his/her complaint referred to the Medical Center's Grievance Committee for further resolution. The complainant may also file his/her complaints directly with the State Department of Health (1250 Punchbowl Street, Honolulu, HI 96813) at 586-4400, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) toll-free at 1-800-994-6610, or the Quality Improvement Organization (for Medicare members) at 545-2550.
14. Cultural and Religious Beliefs
The patient has the right to express spiritual beliefs and cultural practices, as long as these do not harm others or interfere with treatment. The Medical Center will provide pastoral counseling services for patients who request them.
15. Communication Support
The patient has the right to effective communication including the use of Text Teletyping equipment (TTY), or foreign and sign language interpreters. If any form of communication needs to be withheld, including visitors, mail or telephone calls, the patient or his/her legal representative will be involved in the decision.
16. Protective Services
The patient has the right to access protective services. The names and telephone numbers of protective services agencies will be provided upon request.
17. Restraints
The patient has the right to be free from chemical or physical restraints and seclusion except as authorized by a doctor or in an emergency when it is necessary to protect the patient or others from injury. If restraints are indicated, the least restrictive method will be used in accordance with Medical Center policy and the patient will be monitored.
18. Billing Explanation
The patient has the right to a detailed billing explanation and to receive, examine and obtain an itemized bill, regardless of the source of payment. The patient may question charges associated with billing and will be advised of the availability of financial assistance if appropriate.
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