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This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.  If you have any questions about this notice, please contact: 

HIPAA Privacy & Security Officer,
402 W. Lake Street, PO Box 40,
Friendship, WI 53934. (608) 339-8319

Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made.  Typically this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing related information.  This notice applies to all of the records of you or your care generated by the hospital, whether made by hospital personnel, agents of the hospital, or your personal doctor.  Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of our medical information created in the doctor's office or clinic.

Our Responsibilities
We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices.  We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction.  We will accommodate reasonable requests.

Uses and Disclosures
How we may use and disclose Medical Information about you.
Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital.  The information may include your name, location in the hospital, one word condition and your religious affiliation.  This information may be provided to members of the clergy and to other people who ask for you by name.  If you would like to opt out of being in the facility directory, please tell the admission staff.

The following categories describe examples of the way we use and disclose medical information:

For Treatment
We may use medical information about you to provide you treatment or services.  We may disclose medical information about you to doctors, nurses, technicians, medical students or other hospital personnel who are involved in taking care of you at the hospital.  For example: a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.  Different departments of the hospital may also share medical information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals and x-rays.

We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you're discharged from the hospital.

For Payment
We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer.  For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment.  

We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.

For Health Care Operations
Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it.  The results will then be used to continually improve the quality of care for all patients we serve.  For example, we may combine medical information about many patients to evaluate the needs for new services or treatment.  We may disclose information to doctors, nurses and other students for educational purposes; and we may combine medical information we have with that of other hospitals to see where we can make improvements.  We may remove information that identifies you from this set of medical information to protect your privacy.

We may also use and disclose medical information:

  • To business associates we have contracted with to perform the agreed upon service and billing for it
  • To assess your satisfaction with our services
  • To tell you about possible treatment alternatives
  • To tell you about health related benefits or services
  • To inform funeral directors consistent with applicable law
  • For population based activities relating to improving health or reducing health care costs; and
  • For conducting training programs or reviewing competence of health care professionals

Business Associates
There are some services provided in our organization through contracts with business associates.  Examples include physician services in the emergency department, radiology, and certain laboratory tests.  When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill you or your third-party payer for services rendered.  To protect your health information however, we require the business associate to appropriately safeguard your information.

Individuals Involved in Your Care or Payment for Your Care
We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care.  In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.

Future Communications
We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other Community-based initiatives or activities our facility is participating in.

Organized Health Care Arrangement
This facility and its medical staff members have organized and are presenting you this document as a joint notice.  Information will be shared as necessary to carry out treatment, payment and health care operations.  Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.

As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:

  • Food and Drug Administration
  • Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
  • Correctional Institutions
  • Workers Compensation Agents
  • Organ and Tissue Donation Organizations
  • Military Command Authorities
  • Health Oversight Agencies
  • Funeral Directors, Coroners, and Medical Directors
  • National Security and Intelligence Agencies
  • Protective Services for the President and Others

Law Enforcement/Legal Proceedings
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
State-Specific Requirements
Many states have requirements for reporting including population based activities relating to improving health or reducing health care costs.
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the right to:
Inspect and Copy
You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually this means medical and billing records, but does not include psychotherapy notes.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital will review your request and denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for the hospital.  We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
The Right to Get Notice of a Breach
You have the right to be notified upon a breach of any of your unsecured PHI.

An Accounting of Disclosures
You have the right to request an accounting of disclosures.  This is the list of the disclosures we make of medical information about you.
Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care.  We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  We will agree to the request to the extent that it is reasonable for us to do so.  For example, you can ask that we use an alternative address for billing purposes.
Fundraising Activities
We may use or disclose your Protected Health Information, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications. If you do not want to receive these materials, please submit a written request to the Privacy Officer.
A Paper Copy of This Notice
You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.  
To exercise any of your rights, please obtain the required forms by submitting your request in writing.
Changes to This Notice
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future.  The current notice will be posted in the hospital and include the effective date.  In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

If you believe your privacy rights have been violated, you may file a complaint with the hospital by contacting the hospital’s Compliance Officer or with the Secretary of the Department of Health and Human Services.  To file a complaint with the hospital, contact the Compliance Officer, 402 W. Lake Street, PO Box 40, Friendship, WI 53934.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.