Sheboygan Surgery Center Sheboygan Surgery Center
Sheboygan Surgery Center
Patients Bill of Rights & Responsibilities

The staff of the Sheboygan Surgery Center recognizes all patients receiving care at this facility have rights as identified below. In order for us to provide you with the best care possible, you have certain responsibilities as an active participant in your health care.

As a patient, you have the right to

  • be notified in the event your unprotected PHI is intentionally or unintentionally disclosed.
  • request that we not disclose PHI related solely to services for which you have paid for, in full, “out of pocket”. We will accommodate your request, except where we are required by law to make a disclosure.
  • be given a full explanation for a hospital transfer prior to its occurrence, except in an emergency.
  • give or withhold consent to participate in any form of research.
  • be treated with courtesy and respect, with appreciation of individual dignity, and with protection of your need for privacy.
  • a prompt and reasonable response to your questions and requests.
  • know who is providing medical services and who is responsible for your care.
  • know what patient support services are available, including whether an interpreter is available if needed.
  • know what rules and regulations apply to your conduct.
  • be given by your health care provider information concerning diagnosis, a planned course of treatment, alternatives, risks, and benefits.
  • refuse treatment, except as otherwise provided by law.
  • be given, upon request, full information and necessary counseling on the availability of known financial resources for your care.
  • know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.
  • receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
  • receive a copy of a reasonably clear and understandable bill and, upon request, to have charges explained.
  • impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical disability, or source of payment.
  • treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
  • know if medical treatment is for purposes of experimental research and to give your consent or refusal to participate in such experimental research.
  • express concerns regarding any violation of your patient rights.
  • have the right to change primary or specialty physicians or dentists if other qualified physicians or dentists are available.

As a patient, you are responsible for

  • providing to your health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health.
  • reporting unexpected changes in your condition to your health care provider.
  • reporting to your health care provider whether you understand a contemplated course of action and what is expected of you.
  • following the treatment plan recommended by your health care provider.
  • keeping appointments.
  • your actions if you refuse treatment or do not follow your health care provider’s instructions.
  • assuring that the financial obligations of your health care are fulfilled as promptly as possible.
  • following this facility’s rules and regulations affecting patient care and conduct.

Pediatric Patient Rights and Responsibilities - PDF download

We want to assure that you are provided with excellent service, including answering your questions and responding to your concerns. If you have questions or concerns about your rights and responsibilities please feel free to discuss them with one of our Patient Care Staff or contact the Administrative Director of the Sheboygan Surgery Center, 920-208-6470.

You may also contact the State of Wisconsin Bureau of Quality Assurance directly at 2917 International Lane, Suite 300, Madison, WI 53704, or call (608) 234-2024. OR you may contact the CMS-Ombudsman at
1-800-MEDICARE or 1-800-633-4227. Email:

Reviewed September 23, 2013

3141 Saemann Avenue • Sheboygan, WI 53081 (920) 783-5000 •