Woods & Water Medical Center

1019 S. Knowles Ave, New Richmond, WI, 54017 ● (715).246.6561 ● www.WWMC.com

Woods & Water Medical Center wants every patient to receive the best possible care. To that end, we want you to
know what your rights are. For example, it is your right to receive care without discrimination, have you family
involved, participate in planning your medical treatment, complete an advance directive outlining your healthcare
wishes and have your healthcare kept confidential. Specific rights are listed below.
As a patient at Woods & Water Medical Center I, or my legally authorized representative, have the right to:
• Receive care without discrimination due to my race, management or are imposed as a means of coercion,
creed, color, national origin, ancestry, religion, sex, discipline, convenience, or retaliation by staff.
sexual orientation, marital status, age, newborn • Receive evaluation and provision of protective
status, handicap, or source of payment. services.
• Have my family and physician notified promptly of my • Designate who is permitted to visit me during my
admission and have my family participate in my care hospitalization.
decisions. • Receive care and treatment that respects my values,
• Know the name of the physician or other practitioner beliefs, and life philosophy.
who has primary responsibility for my care and know • Address ethical questions that arise in my healthcare.
the identity and professional status of the people • Receive emotional and spiritual support for my family
caring for me. and me.
• Receive from my physician, in terms I can • Complete an advance directive outlining my wishes
understand, current information about my diagnosis, regarding my healthcare should I become unable to
treatment, and prognosis. express my wishes. This may include my wished
• Receive from my physician, except in emergencies, regarding organ and tissue donation.
information that allows me to give informed consent • Refuse treatment to the extent permitted by law and
before beginning and procedure or treatment. be informed of the medical consequences of my
• Participate in the planning of my medical treatment actions.
and to decline to participate in experimental research. • Be informed of the need for, alternative to, and
• Receive care for symptoms that will respond to acceptance by another facility when transfer to that
treatment, even if they are not related to my primary facility is planned.
healthcare condition. • Have all communications and records pertaining to
• Receive evaluation and management of pain. my healthcare confidential.
• Receive considerate and respectful care in a safe and • Have access to my medical record within a reasonable
private environment free of neglect, harassment, and timeframe.
abuse. • Examine and receive an explanation of my bill
• Be free from restraints of any form that are not regardless of the source of payment and receive
medically necessary or are used as a means of information regarding financial assistance.
coercion, discipline, convenience, or retaliation by • Receive information regarding the relationship of
staff. Woods & Water Medical Center to other healthcare
• Be free from seclusion and restraints of any form that of educational institutions involved in my care.
are not necessary for emergency behavior • Receive complete language translation, free of charge

I have read and understood my rights.

Patient Signature Date

April 26, 2021