Your Patient Rights

At Baptist, we know that patients are – first and foremost – people, and people need peace of mind. You know what is best for you, and that includes all decisions related to your life, health and treatment.

Baptist Health System respects your rights as a patient.

Complaints & Grievances

Our mission is to provide our patients with the highest quality health care that we can by meeting your needs, keeping you safe, and making your stay with us as comfortable as possible. To accomplish this we need to know what we are doing right and what needs improvement. We depend on our patients and their families to keep us informed. 

Should we fail to meet your needs or you are dissatisfied with any aspect of your care, the Baptist Health System has adopted procedures to help you let us know about your concerns and take action to help you resolve them. 

Patients or their representative may file a verbal or written complaint or grievance. 

The following are frequently asked questions related to complaints and grievances: 

Q: What should I do if I have a concern or am dissatisfied with my care or hospital stay? 
A: The most important thing you can do is to let us know about it right away. Talk to your nurse or anyone else involved in your care. They will do their best to help you resolve your concern or find someone who can assist you. Most of the time we can take care of things right away, but we can’t help you if we don’t know about your concern. 

Q: I already tried that, and it didn’t work. Now what? 
A: If you feel those providing care to you have not adequately addressed your concerns, contact the manager of the department for assistance. You may also ask to speak with a representative from Administration. Ask your nurse to call and request a visit by the Hospital Administrator, or call the operator and request to speak with Administration. Let them know exactly what the concern is and how they can help. 

Should you need to contact them by telephone, you may contact the hospital operator and request Administration. Dial “0” from a hospital phone. From outside of the hospital, please call the hospital in which you were a patient. The hospital phone numbers are listed below:

  • Baptist Medical Center: (210) 297-7000
  • North Central Baptist Hospital: (210) 297-4000
  • Northeast Baptist Hospital: (210) 297-2000
  • Mission Trail Baptist Hospital: (210) 297-3000
  • St. Luke’s Baptist Hospital: (210) 297-5000

    For all concerns not handled at the time of your complaint, you will receive written acknowledgement of your complaint and written follow up on the outcome of any investigation or corrective action that will include:

  • The name of a contact person at the hospital.
  • The steps the hospital has taken to investigate your complaint/grievance.
  • The results of the complaint/grievance process.
  • The date of completion of the complaint/grievance process.

    Certain Federal and State laws give you specific rights with regard to filing grievances and complaints concerning care and services. 

    Regardless of whether you first use the hospital Complaint/Grievance process you may always contact The Texas Department of State Health Services. 

    Texas law gives you the right to file a complaint related to care and services provided by the hospital with the Texas Department of State Health Services. The address is: 

    Texas Department of State Health Services (TDSHS) 
    1100 West 49th Street 
    Austin, Texas 78756 
    Phone number: 1-888-973-0022 

    Complaints about physicians, as well as other licensees and registrants of the Texas State Board of Medical Examiners, may be reported for investigation at the following address: 

    Texas State Board of Medical Examiners.
    Attn: Investigations Department, MC-263 
    P.O. Box 2018 
    Austin, Texas 78768-2018 
    Phone number: 1-800-201-9353 

    If you have any concerns about patient care and safety in the hospital that the hospital administration has not addressed, please contact the Baptist Health System Regional Offices at (210) 297-1000 and ask to speak with the Vice President of Quality. If you remain dissatisfied, please contact the corporate office of Tenet Healthcare at 1-800-743-6333. If you remain unsatisfied, please contact The Joint Commission (TJC) Office of Quality and Patient Safety by phone at 1-800-994-6610 available weekdays, 8:30 a.m. to 5 p.m. Central Time, by fax (630)792-5636, by email at, or by mailing The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181.

    Interpreter Services Americans with Disabilities Act Compliance

    Interpreter Services - Americans with Disabilities Act Compliance 
    To ensure effective communication with patients and their companions who are deaf or hard of hearing, this hospital provides sign language interpreting services, text telephones (TTYs) and other aids and services to persons who are deaf or hard of hearing.  These services are provided by the hospital free of charge.  Please ask your nurse or other Facility personnel for assistance.

    Interpreter/Sign Language Services & Assistive Devices (TTY/TTD) 
    Interpreter/Sign Language Services and Assistive Devices such as Telecommunication Device for the Deaf (TTY/TTD) are available for persons who are non-English speaking, deaf or hard-of-hearing, and/or blind. These services are at no cost to you.

    The Baptist Health System welcomes all patients with disabilities. This hospital is in compliance with the American Disabilities Act and will provide auxiliary aids and services to patients with disabilities, including American Sign Language (ASL) interpreter services for patients with hearing disabilities to ensure effective communication. When a patient requires an ASL interpreter, the hospital will provide a qualified ASL interpreter who can interpret medical terms free of charge to the patient.

    Patients, family members and visitors requiring special accommodations, including providing auxiliary aids and services for non-English speaking, deaf or hard-of-hearing, and/or blind persons should contact their nurse for assistance or our ADA Representative at (210) 297-8264 or by email address at

    Patients Rights and Responsibilities

    All hospital activities, including care, treatment, and services provided to patients will be directed toward the provision of healthcare in support of patients’ rights. The Baptist Health System (BHS) provides services to patients regardless of their age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. 

    The Baptist Health System respects your rights as a patient. Every patient to include neonate, child, adolescent, adult, and geriatric patient who is receiving care, treatment, and/or services in the Baptist Health System, has the following rights. These rights can be exercised on the patient’s behalf by the legal representative or surrogate decision maker, next available family member(s), parent(s) and/or guardian(s) if the patient lacks decision-making capacity, is legally incompetent, or is a minor: 

  • The hospital respects, protects, and promotes patient rights.
  • The hospital respects the patient’s right to receive information in a manner he or she understands.
  • The hospital respects the patient’s right to participate in decisions about his or her care, treatment, and services.
  • The hospital honors the patient’s right to give or withhold informed consent.
  • You have the right to decide what may be done to your body during the course of medical treatment. Your physician will discuss with you the nature of your condition, the proposed treatment and any alternative procedures that are available. Your physician will also provide you with information about the risks associated with certain medical procedures. This information will help you make an informed decision about the kind of treatment you want to receive.
  • The hospital honors the patient’s right to give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care.
  • The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials.
  • The hospital protects the patient’s right to receive information about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services.
  • The hospital addresses patient decisions about care, treatment, and services received at the end of life.
  • The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.
  • The patient has the right to an environment that preserves dignity and contributes to a positive self-image.
  • The patient and his or her family have the right to have complaints reviewed by the hospital.
  • The patient has the right to access protective and advocacy services.
  • The hospital supports the right of a patient to request and have a chaperone present during certain sensitive physical examinations and treatments.
  • Service Animals – the hospital has a written policy based on (ADA) Americans with Disabilities regulations that define the patient’s right and responsibilities regarding Service Animals.
  • The hospital informs the patient about his or her responsibilities related to his or her care, treatment, and services.

    Download detailed version of the ‘Patient Rights and Responsibilities’ (En Español

    All patients admitted into our Behavioral Health Units will also be given a copy of the patient ‘Bill of Rights’. 

    For additional copies of these ‘Patient Rights and Responsibilities’ and/or ‘Bill of Rights’, please visit any of our Admitting/Registration (Patient Access) areas. Copies are available upon request in English and Spanish. 

    For questions concerning your ‘Patient Rights and Responsibilities’ call our Administration Department at: 

  • Baptist Medical Center: (210) 297-7600
  • Mission Trail Baptist Hospital: (210) 297-3600
  • North Central Baptist Hospital: (210) 297-4600
  • Northeast Baptist Hospital: (210) 297-2600
  • St. Luke’s Baptist Hospital: (210) 297-5600

Service Animal Policy Americans with Disabilities Act Compliance

Service Animals are welcome in all public areas of the hospital. For more detailed information, call BHS ADA Representative at (210) 297-8264 or email

The Joint Commission

Baptist Health System is accredited by The Joint Commission (TJC). If you have questions or concerns about your healthcare facility you may contact TJC directly at the address, below. 

The Joint Commission (TJC)
Office of Quality and Patient Safety
One Renaissance Boulevard 
Oakbrook Terrace, IL 60181 

If you have questions about how to file your complaint, you may contact The Joint Commission at this toll-free telephone number (800) 994-6610, between 8:30 a.m. to 5:00 p.m., Central Time, available weekdays; by fax (630) 792-5636; by email at
; or by mailing The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181.

Medical Records

As a patient, you have the right to inspect or review your medical record. As a courtesy your primary physician will be notified of your request to inspect and/or review your medical record. Your physician or a member of your health team must be present while you inspect or review your medical record. Please note that your medical record is the property of the Baptist Health System. You may obtain a copy of your record, for a fee, after discharge.

If you have questions about your medical record during your stay, please address those questions with your doctor and your nurse.

Notice of Privacy Practices (Version 4, April 2016)

Please click here to view the English and click here for the Spanish version of the Notice of Privacy Practices.


We are committed to protecting the confidentiality of your medical information, and are required by law to do so. This notice describes how we may use your medical information within the Hospital/Clinic and how we may disclose it to others outside the Hospital/Clinic. This notice also describes the rights you have concerning your own medical information. Please review it carefully and let us know if you have questions.

How Will We Use and Disclose Your Medical Information?

Treatment: We may use your medical information to provide you with medical services and supplies. We may also disclose your medical information to others who need that information to treat you, such as doctors, physician assistants, nurses, medical and nursing students, technicians, therapists, emergency service and medical transportation providers, medical equipment providers, and others involved in your care. 

For example, we will allow your primary care physician to have access to your Hospital/Clinic medical record. To assure that your other treatment providers have quick access to your latest health information, we may participate in a community-based electronic health information exchange. We also may use and disclose your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or alternatives, or to tell you about health-related services available to you, or to perform follow-up calls to monitor your care experience. 

Health Information Exchange:  Your PHI may be used and disclosed with other health care providers or other health care entities for treatment, payment and health care operations purposes, as permitted by law, through the Healthcare Access San Antonio Health Information Exchange.  For example, information about your past medical care and current medical conditions and medications can be available to other primary care physicians or hospitals, if they participate in the Healthcare Access San Antonio Health Information Exchange.  Exchange of health information can provide faster access, better coordination of care and assist providers and public health officials in making more informed treatment decisions.  You may opt out of the Healthcare Access San Antonio Health Information Exchange and prevent providers from being able to search for your information through the exchange.  You may opt out and prevent your medical information from being searched through the Healthcare Access San Antonio Health Information Exchange by completing and submitting a HASA Opt-Out Request Form to registration staff.

Patient Directory: In order to assist family members and other visitors in locating you while you are in the Hospital/Clinic, the Hospital/Clinic maintains a patient directory. This directory includes your name, room number, your general condition (such as fair, stable, or critical), and your religious affiliation (if any). We will disclose this information to someone who asks for you by name; we will disclose your religious affiliation only to clergy members. If you do not want to be included in the Hospital’s/ Clinic’s patient directory, please tell our Registration personnel when you are admitted. You may be asked to fill out a simple form. 

Family Members and Others Involved in Your Care: We may disclose your medical information to a family member or friend who is involved in your medical care, or to someone who helps to pay for your care. We also may disclose your medical information to disaster relief organizations to help locate a family member or friend in a disaster. During visits with family members and other visitors, let your physician and Hospital/ Clinic personnel know if you do not want them to disclose your medical information during the visit. 

Payment: We may use and disclose your medical information to get paid for the medical services and supplies we provide to you. For example, your health plan or Health Insurance Company may ask to see parts of your medical record before they will pay us for your treatment. 

Hospital/Clinic Operations: We may use and disclose your medical information if it is necessary to improve the quality of care we provide information to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct business management and planning. For example, we may look at your medical record to evaluate the care provided by Hospital/Clinic personnel, your doctors, or other health care professionals. 

Research: We may use or disclose your medical information for research projects, such as studying the effectiveness of a treatment you received. These research projects must go through a special process that protects the confidentiality of your medical information. 

Required by Law: Federal, state, or local laws sometimes require us to disclose patients’ medical information. For instance, we are required to report child abuse or neglect and must provide certain information to law enforcement officials in domestic violence cases. We also are required to give information to the State Workers’ Compensation Program for work-related injuries. 

Public Health: We also may report certain medical information for public health purposes. For instance, we are required to report births, deaths, and communicable diseases to the State. We also may need to report patient problems with medications or medical products to the Food and Drug Administration (FDA), or may notify patients of recalls of products they are using. 

Public Safety: We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law enforcement officials in response to a search warrant or a grand jury subpoena. We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct, and to report criminal conduct at the Hospital/Clinic. We also may disclose your medical information to law enforcement officials and others to prevent a serious threat to health or safety. 

Health Oversight Activities: We may disclose medical information to a government agency that oversees the Hospital/Clinic or its personnel, such as the State Department of Health, the federal agencies that oversee Medicare, the Board of Medical Examiners or the Board of Nursing. These agencies need medical information to monitor the Hospital’s/Clinic’s compliance with state and federal laws. 

Coroners, Medical Examiners and Funeral Directors: We may disclose medical information concerning deceased patients to coroners, medical examiners and funeral directors to assist them in carrying out their duties. 

Organ and Tissue Donation: We may disclose medical information to organizations that handle organ, eye or tissue donation or transplantation. 

Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed forces, we may release your medical information as required by military command authorities or to the Department of Veterans Affairs. The Hospital/Clinic may also disclose medical information to federal officials for intelligence and national security purposes, or for presidential Protective Services. 

Judicial Proceedings: The Hospital/Clinic may disclose medical information if the Hospital/Clinic is ordered to do so by a court or if the Hospital/Clinic receives a subpoena or a search warrant. You will receive advance notice about this disclosure in most situations so that you will have a chance to object to sharing your medical information. 

Information with Additional Protection: Certain types of medical information have additional protection under state or federal law. For instance, medical information about communicable disease and HIV/AIDS, and evaluation and treatment for a serious mental illness is treated differently than other types of medical information. For those types of information, the Hospital/Clinic is required to get your permission before disclosing that information to others in many circumstances.

When is Your Authorization Required?

Uses and Disclosures for Which Your Authorization is Required: With limited exceptions, the Hospital/Clinic must obtain your written authorization before it may disclose your medical information in the following circumstances: (1) to disclose psychotherapy notes, (2) to conduct marketing activities, or (3) to sell your medical information to a third party.

Other Uses and Disclosures Requiring Authorization: If the Hospital/Clinic wishes to use or disclose your medical information for a purpose that is not discussed in this Notice, the Hospital/Clinic will seek your written authorization. If you give your authorization to the Hospital/Clinic, you may take back that authorization any time, unless we have already relied on your authorization to use or disclose the information.

If you ever would like to revoke your authorization, please notify the Privacy Official in writing.

What Are Your Rights?

Right to Request Your Medical Information: You have the right to look at your own medical information and to get a copy of that information.  (The law requires us to keep the original record.) This includes your medical record, your billing record, and other records we use to make decisions about your care. To request your medical information, write to the Privacy Official. If you request a copy of your information, we will charge you for our costs to copy the information. We will tell you in advance what this copying will cost. You can look at your record at no cost.

Right to Request Amendment of Medical Information You Believe Is Erroneous or Incomplete: If you examine your medical information and believe that some of the information is wrong or incomplete, you may ask us to amend your record. To ask us to amend your medical information, write to the Privacy Official.

Right to Get a List of Certain Disclosures of Your Medical Information: You have the right to request a list of many of the disclosures we make of your medical information. If you would like to receive such a list, write to the Privacy Official. We will provide the first list to you free, but we may charge you for any additional lists you request during the same year.  We will tell you in advance what this list will cost. 

Right to Request Restrictions on How the Hospital/Clinic Will Use or Disclose Your Medical Information for Treatment, Payment, or Health Care Operations: You have the right to request that the Hospital/Clinic not make disclosures of your medical information to treat you, to seek payment for care, or to operate the Hospital/Clinic. In many cases, the Hospital/Clinic is not required to agree to your request for restriction, but if we do agree, we will comply with that agreement.  If you want to request a restriction, write to the Privacy Official and describe your request in detail. However, the Hospital/Clinic must agree to your request not to disclose to your health plan any medical information about items or services for which you have paid in full, unless such disclosure is required for treatment or by law. If you do not want the Hospital/Clinic to disclose medical information to your health plan, you must notify us at the time of your registration as well as make immediate arrangements to pay in full for your treatment.

Right to Request Confidential Communications: You have the right to ask us to communicate with you in a way that you feel is more confidential. For example, you can ask us not to call your home, but to communicate only by mail. To do this, write to the Privacy Official.  Upon request, you can also ask to speak with your health care providers in private outside the presence of other patients or family.

Right to a Paper Copy: If you have received this notice electronically, you have the right to a paper copy at any time. You may download a paper copy of the notice from our Web site, by clicking here, or you may obtain a paper copy of the notice from the Privacy Official.

Duties of the Hospital

The Hospital/Clinic is required by law to protect the privacy of your medical information, give you this Notice of Privacy Practices, and follow the terms of the Notice that is currently in effect. The Hospital/Clinic is also required to notify you if there is a breach of your unsecured medical information.

Which Health Care Providers are Covered by this Notice?

This Notice of Privacy Practices applies to the Hospital/Clinic and its personnel, volunteers, students, and trainees. The Notice also applies to other health care providers when they come to the Hospital/Clinic to care for patients, such as physicians, physician assistants, therapists, other health care providers who are not employed by the Hospital/Clinic. However, these other health care providers may follow different practices at their own offices or facilities.

Changes to this Notice

From time to time, we may change our practices concerning how we use or disclose patient medical information, or how we will implement patient rights concerning their information. We reserve the right to change this Notice and to make the provisions in our new Notice effective for all medical information we maintain. If we change these practices, we will publish a revised Notice of Privacy Practices. You can get a copy of our current notice of Privacy Practices at any time by contacting the Privacy Official.


Please tell us about any problems or concerns you have with your privacy rights or how the Hospital/Clinic uses or discloses your medical information.  If you have a concern, please contact the Hospital’s/Clinic’s Privacy Official or call the Ethics Action Line (EAL): Ethics Action Line (EAL): 1-800-8-ETHICS.

If for some reason the Hospital/Clinic cannot resolve your concern, you may also file a complaint with the federal government at the OCR/DHHS regional office. We will not penalize you or retaliate against you in any way for filing a complaint with the federal government.

Practice Privacy Official Contact Information

Name: Michael Tamayo, Regional HIPAA Privacy Officer
Mailing Address: 1445 Ross Avenue, Suite 1400; Dallas, Texas  75202     
Phone:(877) 893-8363 ext. 2009 or (469) 893-2311


Notice to Patient Destruction of Medical Records

In accordance with Texas Health and Safety Code, Section 241.103, this notice is given to you regarding the destruction of medical records. 

It is the policy of the Hospital/Clinic to authorize the disposal of any medical records on or after the tenth (10th) anniversary of the date on which you, the patient, were last treated at this facility.

If you, the patient, are younger than 18 years of age when you were last treated, the Hospital/Clinic may authorize the disposal of medical records relating to you, the patient, on or after your twentieth (20th) birthday, or on or after the tenth (10th) anniversary of the date on which you were last treated, whichever date is later.

The Hospital/Clinic will not destroy medical records that relate to any matter that is involved in litigation if the Hospital/Clinic knows the litigation has not been fully resolved.

Effective date: September 23, 2013 v. 4 Rev. 04/16