Patient and Family Rights and Responsibilities 

While you are a patient at our hospital, we will treat you with the respect due each person. You are entitled to high quality care that responds to your physical, emotional, social, psychological, and spiritual well-being.
 

Standards for Privacy of Protected Health Information

According to the federal law named, “Health Insurance Portability and Accountability Act”(HIPAA), you have rights concerning the use of your individually identifiable health information .Only individuals with a legitimate “need to know” may access, use or disclose patient information .Protected health information may be released to others without patient authorization if used for purposes of treatment, payment, health care operations, or as permitted by state or federal laws .Other disclosures of protected health information require patient authorization.
 
While receiving care in the hospital, you may ask that your name not be included in the hospital directory, which means that people asking for you will be told, “I have no information about this patient.” If you want to receive deliveries of cards and flowers, your name must be included in the hospital directory. If you include your name in the hospital directory, you name will appear on a list for clergy members of your faith. 
 
For a listing of other HIPAA privacy rights, please refer to the Notice of Privacy Practices that was given to you when you were admitted.
 

Rights Related to Respect and Dignity 

  • To be informed of your rights in writing. 
  • To receive dignified and respectful treatment of your unique personal and health needs. 
  • To an environment and treatment that protects your rights, supports dignity, and contributes to a positive self-image.  
  • To respect your cultural and personal values, religious and spiritual beliefs and preferences important to you. 
  • To ask for emotional, spiritual and pastoral support. 
  • To religious or spiritual services and to ask your clergy person to visit. 
  • To keep and use personal clothing and possessions if medically allowed. 
  • To have a family member or someone you choose notified promptly of your admission to the hospital. 
  • To have a family member, friend or another person present for emotional support during your stay. 
  • To have your hospital room respected as your home. 
  • To receive visitors you designate and receive phone calls and mail. 
  • To withdraw or deny your consent to visitors. 
 

Rights Related to Access to Care 

  • To have access to treatment that is available and medically appropriate, regardless of age, race, ethnicity, national origin, ancestry, creed/religion, culture, language, physical or mental disability/handicap, socioeconomic status, gender, sexual orientation, gender identity or expression, newborn status or source of payment.
  • To an environment of care. 
  • To service with or without an Advance Directive. 
  • To know the financial consequences of using uncovered services or out of network providers. 


Privacy and Confidentiality Rights 

  • To personal privacy. 
  • To receive a copy of our Notice of Privacy Practices. 
  • To confidentiality of medical information. 
  • To access your medical record and request changes if it is not correct, relevant, or complete. 
  • To access information in your clinical records within a reasonable timeframe. 
  • To ask for information on disclosures of your health information, in accordance with law and regulation. 
  • To give or withhold informed consent to produce or use recordings, films, or other images for purposes other than your care. 
 

Pain Management Rights 

  • To have resources to recognize your pain. 
  • To have your pain believed and managed. 
  • To have your pain assessed and reassessed. 
  • To have a pain management plan of care. 
 

Rights Related to Safety 

  • To receive care in a clean and safe place. 
  • To be free from neglect, exploitation, harassment, abuse and potential abuse situations while you are receiving care, treatment and services. 
  • To have allegations, observations and suspected cases of neglect, exploitation, and abuse that occur within the hospital evaluated by the hospital. 
  • To access protective and advocacy services. 
  • To names, addresses, and phone numbers of patient advocacy groups when requested. 
 

Rights Related to Communication 

  • To effective communication. 
  • To receive information suited to your age and language in a way that you can understand. 
  • To receive information in a way that meets your needs for vision, speech, hearing, or cognitive assistance. 
  • To hospital-provided interpreter services. 
  • To accurate and easily understood information about your health care. 
  • To know what to expect during your hospital stay. 
  • To talk privately with health care providers and have your health care information protected. 
  • To voice concerns about quality of care and receive a timely response. 
  • To communicate with administration if you desire. 
  • To evaluation of any concerns about your stay. 
 

Rights Related to Care, Treatment and Services 

  • To know the name of the physician, clinical psychologist, or other practitioner who has primary responsibility for your care, treatment or services. 
  • To have your physician promptly notified of your admission to the hospital. 
  • To know and understand your condition, diagnosis, and prognosis. 
  • To participate in the development and implementation of your plan of care and decisions about your care. 
  • To respect your health care goals and to know the likelihood of achieving them. 
  • To have a surrogate decision maker involved in your decisions if you are unable to make decisions about your care. 
  • To make informed decisions with your doctor and give or withhold consent for care, after a discussion of risks, benefits, and potential side effects and the risks related to not receiving the proposed care, treatment and services. 
  • To know what to expect from your treatment and any long-term effects it might have on your quality of life. 
  • To be notified of unanticipated outcomes of care, treatment and services, including injury or error. 
  • To have your family involved in your care to the extent you or your surrogate decision maker permit in accordance with law and regulation. 
  • To an appropriate level of care or service. 
  • To know of problems that might occur during recuperation. 
  • To freedom from unnecessary medication and restraints. 
  • To request care, treatment and services. 
  • To refuse care, treatment and services in accordance with law and regulation. 
  • To request, accept or refuse to participate in clinical research. 
  • To receive information and help in deciding whether or not to participate in the research by  receiving an explanation of the purpose of the research, the expected duration of the patient’s participation, a clear description of the procedures to be followed, a statement of the potential benefits, risks, discomforts, and side effects, and alternative care, treatment, and services available to the patient that might prove advantageous to the patient. 
  • To know if your treatment is experimental or part of a research study. 
  • Except in an emergency, to not be transferred to another facility without full explanation of the transfer, provision of the continuing care and acceptance by the receiving institution. 
  • To have your decisions about care, treatment, and services received at the end of life. 
 

Rights Regarding Advance Directives 

  • To be asked if you have an Advance Directive. 
  • To have written information about Advance Directives. 
  • To assistance in formulating or updating an advance directive. 
  • To have staff honor your Advance Directives or know if the hospital or outpatient setting cannot honor your Advance Directive in accordance with the Ethical and Religious Directives for Catholic Healthcare Services. 
  • To review or revise your Advance Directive. 
  • To forego or withdraw life-sustaining treatment, or withhold resuscitative services. 
  • To end-of-life care. 
  • – To have your wishes documented regarding organ donation. 

Rights Related to When You Leave the Hospital 

  • To help when leaving the hospital. 
  • To know what you and your family need to do after you leave the hospital. 
  • To request and receive detailed information about the cost of your care and to receive an explanation of your bill. 
  • To help with your billing claims. 
 

Patient Responsibilities 

For our hospital to provide you with the best care possible, you need to: 
  • Provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other health-related things. 
  • Report changes in your medical condition. 
  • Ask questions if you do not understand care, treatment or services. 
  • Provide a copy of your Advance Directive if you have one. 
  • Show mutual respect by being civil in interactions with providers and staff. 
  • Follow instructions, policies, rules and regulations to support quality care and a safe environment for all. 
  • Be considerate of other patients, visitors and hospital staff and others’ property. 
  • Follow health care professionals’ recommendations for smoking cessation, weight reduction and diet. 
  • Follow plan of care or accept responsibility for the outcomes if you do not follow instructions. 
  • Leaving against medical advice makes you responsible for outcomes resulting from not following the recommended treatment plan. 
  • Follow rules and regulations regarding infection control and patient safety. 
  • Provide honest feedback about our services and expectations. 
  • Restrict minors in certain areas. 
  • Restrict use of cell phones next to critical care equipment. 
  • Meet your financial commitments and ask questions if you need information. 
  • Ensure that the hospital has correct billing information. 
 

Your Right to Make a Complaint and the Resolution Process 

You have the right to be informed of the complaint process, to know what department or agency to contact to file a complaint, to a fair, prompt and objective review and resolution of any grievance. You will not be subject to retribution for filing a complaint. If needed, arrangements can be made for an interpreter. Pastoral Care and Care Management employees act as your advocates.
  • HSHS St. Mary’s Hospital Medical Center and HSHS St. Vincent Hospital Care Management: 920-433-8638 
  • HSHS St. Mary’s Hospital Medical Center Pastoral Care: 920-498-4281 
To have your concerns regarding quality of care or premature discharge referred to the appropriate 
quality improvement organization, see the list below. 
 
Hospital 
Any patient or patient’s family member may file a complaint with a member of the hospital staff .We respond to complaints to seek resolution. Complaints related to quality or discrimination are handled in the Risk Management Department.
 
Risk Management Department: Extension 45719
 
The Patient Financial Services Department handles financial complaints. 
Patient Financial Services: Extension 48122 
(If you are calling from outside the hospital (920) 433-8122 or 1 (800) 211-2209). 

The Privacy Officer handles privacy concerns. 
Privacy Officer: Extension 58513 
Or you can contact the Privacy Officer in writing at: 
Privacy Officer, Responsibility Department
P .O. Box 13508 Green Bay, WI 54307-3508  
 
Local 
For abuse, neglect or safety issues with patients contact the Brown County Human Services,920-448-6000 
 
State 
You may contact the Wisconsin Department of Health Services – Bureau of Health Services of the Division of Quality Assurance, at1 (800) 642-6552 . 
 
Federal 
If you believe your privacy or patient rights were violated, you may file a complaint with the U .S. Department of Health and Human Services Office for Civil Rights, 233 North Michigan Avenue, Suite 240, Chicago, IL 60601, or call 1 (800) 368-1019. 
 
Compliance 
We prohibit discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, gender, sexual orientation, and gender identity or expression. We comply with the equal opportunity policy and standards of the Department of Workforce Development, Department of Health and Family Services and all applicable State and Federal statutes and regulations relating to nondiscrimination in service delivery. 
 

If you have a Question or Concern 

Patient satisfaction is HSHS St. Mary’s Hospital Medical Center’s goal. We seek to treat our patients with fairness and concern, recognizing their needs and satisfying them to the extent possible. If you or your loved one has a question or concern about the care you receive or if you don’t understand something, please let us know right away so we may better serve you. It is your right to register a complaint or concern without fear of retribution .You may direct your concern to the attention of any staff member. If we are unable to resolve your concern to your satisfaction, you may contact the hospital’s Risk Manager at (920) 844-5719. In addition, if you believe your complaint has not been adequately resolved within 30 days you may send your grievance to: 
 
Bureau of Quality Assurance Health Services Section
P .O. Box 2969, Madison, WI 53701-2969
or call (608) 266-8481
 
The public may contact the Joint Commission’s Office of Quality Monitoring to report any concerns or register complaints about a Joint Commission-accredited health care organization by either calling 1-800-994-6610 or emailing complaint@jointcommission.org. 
 
 
 
 
 
 
 
 
Notice of Nondiscrimination:  English

Language Assistance:  Español | Hmoob | Deutsch | Français | 繁體中文 | Deitsch | Polski | العربية | Русский | Italiano | Tagalog | हिंदी  | ພາສາລາວ | 한국어 | Tiếng Việt | اُردُو |