Notice Of Privacy, Patient Information

The following 3 online forms contain extremely important information concerning your rights, your responsibilities, ownership, grievance reporting and our advance directive policy.  Please take a few moments to review these pages.  

In the event of a serious medical emergency, it is the policy of our office to provide medical care addressing that emergency until the patient can be transferred to a higher level facility (i.e. hospital).

Patient Rights

  1. Exercise these rights without regard to sex or cultural, economic, educational or religious background or the source of payment for his/her care without reprisal.
  2. Receive information from his/her physician about his/her illness, course of treatment and prospects for recovery in terms that he/she can understand.
  3. Receive as much information about any proposed treatment or procedure as he/she may need, in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternate course of treatment or non-treatment and the risks involved in each, and to know the name of the person who will carry out the procedure or treatment.
  4. Participate actively in decisions regarding his/her medical care. To the extent permitted by law, this includes the right to refuse treatment.
  5. Full consideration of privacy concerning his/her medical care program; Case discussion, consultation, examination and treatment are confidential and shall be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual.
  6. Confidential treatment of all communications and records pertaining to his/her care and stay in the center. His/her written permission shall be obtained before his/her medical records can be made available to anyone not directly concerned with his/her care.
  7. Reasonable responses to any reasonable request he/she may make for service.
  8. Leave the surgery center even against the advice of his/her physician; Reasonable continuity of care and to know in advance the time and location of appointment, as well as the physician providing the care.
  9. Be advised if the surgery center or personal physician proposes to engage in or perform human experimentation affecting his/her care or treatment. The patient has the right to refuse to participate in such research projects without compromising access to care.
  10. Be informed by his/her physician, or a delegate of his/her physician, of the continuing health care requirements following his/her discharge from the surgery center.
  11. Receive information regarding fees and payment schedule.
  12. Examine and receive an explanation of his/her bill regardless of source of payment.
  13. Know which surgery center rules and policies apply to his/her conduct while a patient.
  14. Have all patient rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.
  15. Have the right to refuse care, treatment, and services in accordance with law and regulation.
  16. Have the right to be informed, and when appropriate their families, about the outcomes of care, treatment, and services, including unanticipated outcomes.
  17. Have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation.
  18. All personnel shall observe these patient rights.

Our center is dedicated to the provision of quality care and your opinion of the care provided is important to us. If you feel you have been treated unfairly, without respect, or treated inappropriately, please contact the administrative office at 714-842-2521 or/and the office of Medicare Ombudsman at and/or Orange County Department of Health at 714-456-0630 Jackie Lincer, District Administrator. They will listen to you and direct your compliment-complaint or observation to the appropriate individual and/or committee for resolution.

You can also notify JCAHO Department of Quality Monitoring regarding your experience with our center at 1-800-994-6610 or email to www.


The patient is responsible to:

1.Provide accurate and complete and accurate information concerning his/her present complaints, past medical history and any medications, including over-the-counter products and dietary supplements, allergies or sensitivities and other matters relating to his/her health. 2.Inform the center about any living will, medical power of attorney or other directive that could effect the patients care. 3.Make it known whether he/she clearly comprehends the course of his/her medical treatment and what is expected of him/her. 4.Follow the treatment plan established by his/her physician, including the instructions of nurses and other health professionals, as they carry out the physician’s orders. 5.His/her actions should he/she refuses treatment or not follow his/her physician’s orders. 6.Accept financial obligations 7.Have a responsible adult to transport him/her home from the facility and remain with
him/her for 24 hours, if requires by his/her provider.
8. Be respectful and considerate of all the rights of other patients and facility personnel.

Ownership Information

Dr. Daniel Levin owns this surgical Practice. If you wish to speak with Dr. Levin about the care provided, please contact him at 714-842-2521.

Grievance Reporting

Huntington Beach Center for Maxillofacial Services, Inc. is dedicated to the provision of quality care and your opinion of the care provided is important to us. If you feel you would like to compliment us or feel you have been treated unfairly, without respect, or treated inappropriately, please contact the administrative office at 714-842-2521. They will listen to you and direct the complaint or observation to the appropriate individual and/or committee for resolution within 60 days.

Advanced Directive Policy

It is the policy of the center to advise the patient verbally and in writing prior to the day of surgery and to ask the patient if they have an advanced directive during the pre-admission phone call. If the patient has an advanced directive, we ask if the advance directive contains a “DO NOT RESUSCITATE” (DNR) clause. If the patient indicates they do have a DNR clause they are advised that the center does not honor DNR’s.

The patient is advised that they will waive the DNR portion of their advance directive when they sign the consent/permit prior to the procedure. The center will not perform surgery on patients that have advanced directives, unless they agree to be resuscitated.

If the patient does not waive the DNR, the procedure will be scheduled at the hospital.


Huntington Beach Center for Maxillofacial Services, Inc.


Prior to the day of my surgery I have received:

  • My Patient Rights
  • My Responsibilities
  • Physician Ownership Information
  • Compliments/Grievance Policy
  • Advance Directive Policy with Authority to Resuscitate
  • I have been explained the centers’ policy on Advance Directives.

Consent to Resuscitation

This signed registration under Notice of Privacy implies your consent for resuscitation and transfer to a higher level of care should the patient suffer a cardiac or respiratory arrest or other life-threatening situation. Each patient has a right to self-determination, which encompasses the right to make choices regarding life-sustaining treatment (including resuscitative services).

If you wish to receive a copy of the California Health Care Directive form please advise the receptionist.