Ambulatory surgery center - patient rights & responsibilities

As a patient, you have the right to:

• Every patient has the right to be informed of his/her rights in a manner he/she can understand and to exercise these rights without being subjected to discrimination or reprisal. 
• Every patient has the right to courtesy, respect, dignity, privacy responsiveness, and timely attention to his/her needs regardless of age, race, sex, national origin, religion, cultural, or physical handicap, personal values, preferences, and beliefs.  
• Every Patient has the right and need for effective communication.  
• Every patient has the right to every consideration of his privacy and individuality as it relates to his social, religious and psychological wellbeing.   
• Every patient has the right to confidentiality. Has the right to approve or refuse the release of medical information to any individual outside the facility, except in the case of transfer to another health facility, or as required by law or third-party payment contract.   
• Every patient has the right to express grievances or complaints without fear of reprisals.  
• Every patient has the right to a safe environment.   
• Every patient has the right to continuity of health care. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient sufficient opportunity to make alternative arrangements.   
• Every patient is provided complete information regarding diagnosis, treatment and prognosis, as well as alternative treatments or procedures and the possible risks and side effects associated with treatment. If medically inadvisable to disclose to the patient such information, the information is given to a person designated by the patient or to a legally authorize individual.   
• Every patient has the right to be free from any act of discrimination or reprisal.   
• Every patient has the right to make decisions regarding the health care that is recommended by the physician, accordingly, the patient may accept or refuse any recommended medical treatment and must be informed of the consequences of his/her actions. 
• Every patient has the right to be informed of any research or experimental projects and to refuse participation without compromise to the patient’s usual care.   
• Every patient has the right to appropriate treatment and care to include the assessment/management of pain.   
• Every patient has the right to an explanation of and to understand facility charges related to his/her
• health care.   
• Every patient has the right to all resuscitative measures: therefore, we will not honor Advance Directives.  
• Every patient has the right to be free from all forms of abuse or harassment.   
• Every patient has the right to personal privacy. 
• Every patient has the right to change providers if other qualified providers are available. 

As a patient, it is your responsibility to:

• Patients are responsible to be honest and direct about matters that relate to them, including answering questions honestly and completely.  
• Patients are responsible to provide complete and accurate past and present medical history, present complaints, past illnesses, hospitalizations, surgeries, existence of advance directive, any medications taken, including over the counter products and dietary supplements, any allergies or sensitivities, and other pertinent data to the best of their ability.  
• Patients are responsible to follow the treatment plan prescribed by his/her provider and participate in his/her care.
• Agree to accept all care givers without regard to race, color, religion, sex, age, gender reference or handicap, or national origin.  
• Patients are responsible for assuring that the financial obligations for health care rendered are paid in a timely manner.  
• Patients are responsible to sign required consents and releases as needed.  
• Patients are responsible for their actions if they should refuse a treatment or procedure, or if they don’t follow up or understand the instructions given them by the physician or Surgery Center employees.  
• Patients are responsible for keeping their procedure appointment, if they anticipate a delay or must cancel, they will notify the Surgery Center as soon as possible.  
• Patients are responsible for the disposition of their valuables, as the Surgery Center does not assume the responsibility.  
• Patients are responsible to be respectful of others, other people’s property, and the property of the Surgery Center.  
• Patients are to observe safety and no smoking regulations.  
• Patients are responsible for providing a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, if required by the provider. 

Grievances

If you have a complaint or grievance, please call the center at 920-272-1098 and ask for

the ASC Director.  

If your complaint or grievance was not resolved, you may call/mail any of the below:

• Wisconsin Department of Health:  DHSwebmaster@dhs.wisconsin.gov

Department of Health Services 1 West Wilson Street • Madison, WI 53703

General phone number: 608-266-1865

TTY phone number: 711 or 800-947-3529 

• Office of Medicare Beneficiary Ombudsman: http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html
• Medicare: www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227)