. Patient Rights and Responsibilities for Patient, Patient Representative or Surrogate – GI Associates
Patient portal sign in

Patient Rights and Responsibilities

for Patient, Patient Representative or Surrogate

Printed copy of the Patient Rights & Responsibilities available upon request.

Patients have the right to:
• Respect, consideration, dignity, comfort and personal privacy
• Treatment in a safe environment free from discrimination, abuse, harassment and/or neglect
• Request and/or decline a medical chaperone during a sensitive examination
• Confidentiality regarding records with the opportunity to approve or refuse release, except when required by law
• Complete information about their diagnosis, evaluation, treatment and prognosis
• Participation in health care decision-making except when contraindicated for medical reasons
• Request staff credentials and/or change providers if other qualified providers are available
• Reasonable accommodations for disabilities and interpreter services
• Information about fees for services and payment policies
• Information regarding services available, after hours and emergency care
• Information on advance directives and/or resources for developing an advance directive
• Information for exercising rights and expressing complaints and/or grievances without fear of reprisal, discrimination or care interruptions
• Legal representation, or if adjudged incompetent under applicable State laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under State law to act upon their behalf
• Refuse participation in research

Patients are responsible to:
• Provide complete and accurate information, to their best their ability, about their health, medications, including over-the-counter products and dietary supplements and allergies or sensitivities
• Participate in their care and follow the treatment plan prescribed by their provider
• Behave respectfully toward the health care team and other patients and visitors at the facility
• Provide a responsible adult to accompany them home after sedation
• Accept personal financial responsibility for any charges not covered by their insurance
• Disclose advance directives that could affect care including medical power of attorney (POA), do not resuscitate (DNR) or other directives

Advance Directive
Due to the elective nature of this procedure, DNR advance directives are suspended. In the event of a life-threatening emergency, efforts are made to resuscitate all patients. Transfer to a hospital will be completed where DNR will be reinstated.

Disclosure Statement
Center for Digestive Health, SC, and Mayfair Digestive Health Center, LLC, are owned by Midwest GI Specialists, LLC. Lake Country Endoscopy Center, LLC, GI Specialists, LLC DBA Moreland Endoscopy Center and Southern Lakes Endoscopy Center, LLC, are owned by ProHealth Care and Midwest GI Specialists, LLC. Racine Digestive Health Center, LLC, and Kenosha Digestive Health Center, LLC, are owned by Columbia St. Mary’s, Inc. and Midwest GI Specialists, LLC. All GI Associates physicians have financial interest or ownership in endoscopy centers (see printed copy for list of individual physicians).

For grievances regarding patient rights and responsibilities, contact:
GI Associates Compliance Officer at 414-266-9212 

Additional contacts:
Wisconsin Department of Health Services
Division of Quality Assurance
Compliance Intake
1 West Wilson Street
Madison, WI 53703
608-266-8481/800-642-6552

Office of the Medicare Beneficiary Ombudsman
1-800-Medicare (1-800-633-4227)
TTY: 1-877-486-2048
https://www.medicare.gov/basics/your-medicare-rights/get-help-with-your-rights-protections
https://www.medicare.gov/claims-appeals