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Wild Rose Community Memorial Hospital
601 Grove Ave
PO Box 243
Wild Rose, WI 54984
920-622-3257
920-622-5593 fax
Hours – 24/7

Waushara Family Physicians – Wild Rose
701 Grove Ave
PO Box 314
Wild Rose, WI 54984
920-622-5560
920-622-5598 Fax
Hours – 8a-8p

Waushara Family Physicians – Plainfield
N6493 Valley Circle Dr
PO Box 5
Plainfield, WI 54966
715-335-6506
715-335-6546 Fax
Hours – 8a-5p

Waushara Family Physicians – Wautoma
N2934 Hwy 22 N
PO Box 708
Wautoma, WI 54982
920-787-0840
920-787-0842 Fax
Hours – Please call for clinic hours

Waushara Family Physicians – Coloma
141 Front St
PO Box 219
Coloma, WI 54930
715-228-2300
715-228-2302 Fax
Hours – Please call for clinic hours

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HIPAA Privacy Policy

WILD ROSE COMMUNITY MEMORIAL HOSPITAL NOTICE OF PRIVACY PRACTICES                        

Effective as of 04-14-03

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.

Wild Rose Community Memorial Hospital (WRCMH) uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.  Your health information is contained in a medical record that is the physical property of WRCMH.

HOW WRCMH MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

For TreatmentWRCMH may use or disclose your health information to provide you with medical treatment or services.  For example, information relative to your treatment will be obtained and recorded in your record by a health care provider, such as a physician, nurse, or other person providing health services to you.  This information is necessary for health care providers to determine what treatment you should receive.  Health care providers will also record actions taken by them in the course of your treatment and note how you respond to their actions.  We will provide general information about your condition unless you tell us otherwise.  In an emergency situation where you are unable to function, health information may be disclosed to those involved in your care.  You have a right to object to further disclosures when you are able to make your wishes known.

For Payment  WRCMH may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive.  For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan.  The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment. 

For Health Care Operations  WRCMH may use and disclose health information about you for operational purposes.  For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:

  • Evaluate the performance of our staff;
  • Assess the quality of care and outcomes in your cases and similar cases;
  • Learn how to improve our facilities and services; and
  • Determine how to continually improve the quality and effectiveness of the health care we provide.  (Examples include reviews by outside peers, including by limited to MetaStar, NCQA, RWHC, and OHCI, to provide continuing education to staff.  Audit trails may not be available).

 

For Appointments  WRCMH may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

As Required by Law  WRCMH may use and disclose information about you as required by law.  For example, WRCMH may disclose information for the following purposes:

  • For judicial and administrative proceedings pursuant to legal authority;
  • To report information related to victims of abuse, neglect or domestic violence; and
  • To assist law enforcement officials in their law enforcement duties.

 

For Public Health  Your health information may be used or disclosed for public health activities, such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

For Decedents  Health information may be used or disclosed for cadaveric organ, eye, or tissue donation purposes.

For Research  WRCMH may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.

For Health and Safety  Your health information may be disclosed to avert a serious threat to the health or safety of you and any other person pursuant to applicable law.

For Government Functions  Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services.

For Workers' Compensation Issues  Your health information may be used and disclosed in order to comply with laws and regulations related to Workers' Compensation.

For Other Uses  Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent WRCMH has taken action in reliance on such.

YOUR HEALTH INFORMATION RIGHTS:

You have the right to:

  • Request a restriction on certain uses and disclosures of your protected health information and you have the right to request that we limit our disclosure of your information to individuals involved in your care or the payment for your care; however, WRCMH is not required to agree to a requested restriction;
  • Obtain a paper copy of the notice of information practices upon request;
  • Inspect and obtain a copy of your health record - our organization may charge a fee for costs of copying, mailing, labor and supplies associated with your request;
  • Request that your health record be amended;
  • Request confidential communications of your health information by alternative means or at alternative locations; and
  • Receive an accounting of disclosures made of your health information other than for payment, treatment, and health care operations.

More information may be found in 45 C.F.R. (Code of Federal Register)

CONCERNS/COMPLAINTS

You may file a concern with WRCMH and with the Department of Health and Human Services if you believe your privacy rights have been violated.  You will not be retaliated against for filing a complaint.

Wild Rose Community Memorial Hospital                                             Department of Health and Human Services

ATTN:  Privacy Officer                                                                       200 Independence Ave., S.W.

PO Box 243                                                                                      Washington, DC 20201

Wild Rose, WI 54984                                                                         (202) 690-7000

(920) 361-5551

OBLIGATIONS OF WRCMH

WRCMH is required by law to:

  • Maintain the privacy of protected health information;
  • Provide you with this notice of its legal duties and privacy practices with respect to your health information;
  • Abide by the terms of this notice;
  • Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
  • Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and

WRCMH reserves the right to change its information practices and make the new provisions effective for all protected health information it maintains.  Revised notices will be made available to you upon request, at your next registration, or at our website.

CONTACT INFORMATION

If you have any questions or concerns, please contact:

Wild Rose Community Memorial Hospital

ATTN:  Privacy Officer

PO Box 243, Wild Rose, WI 54984

(920) 361-5551

Effective as of 04-14-03