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HIPAA Privacy Policy



Effective as of 08-19-2013


Wild Rose Community Memorial Hospital NOTICE OF PRIVACY PRACTICES




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.




For Treatment. WRCMH may use or disclose your health care information in the provision, coordination or management of your health care. WRCMH’s communications to you may be by telephone, cell phone, e-mail, patient portal, or by mail. For example, WRCMH may use your information to call and remind you of an appointment or to refer your care to another physician. If another provider requests your health information and they are not providing care and treatment to you we will request an authorization from you before providing your information.


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;


   Determine how to continually improve the quality and effectiveness of the health care we provide, including, for example, things like reviews by outside peers;


   To health agencies to conduct health oversight activities including audits, investigations, inspections, licensure and other proceedings related to oversight of the health care system; and,


   Provide appointment reminders or information.


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 example, we may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purposes. Under some limited circumstances we will request your authorization prior to permitting disclosure.


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. Health information may also be disclosed to coroners and medical examiners.


For Research. WRCMH may use your health information for research purposes under certain circumstances, and only after a special approval process, to help conduct medical 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. Under certain circumstances, 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.


WRCMH Directory. Unless you object, we may use your health information, such as your name, location in our facility, your general health condition (e.g., “stable,” or “unstable”), and your religious affiliation for our directory. It is our duty to give you enough information so you can decide whether or not to object to release of this information for our directory. The information about you contained in our directory will not be disclosed to individuals not associated with our health care environment without your authorization.




Except as described in this Notice of Privacy Practices, WRCMH will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of psychotherapy, marketing, and the sale of protected health information require your authorization. With your authorization, WRCMH can use your protected health information to engage in marketing and fundraising. You have the right to opt out of receiving such communications. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.


Your Health Information Rights:


You have the right to:


   Request a restriction on certain uses and disclosures of your protected health information, including but not limited to, disclosures to health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the protected health information pertains solely to a health care item or service has been paid for in full.


   Obtain a paper copy of the Notice of Privacy Practices upon request;


   Inspect and obtain a copy of your health record, although WRCMH may charge a fee for costs of copying, mailing, labor and supplies associated with your request;


   Request that your health record be amended pursuant to WRCMH’s policy, although WRCMH is not necessarily required to make requested amendments;


   Request confidential communications of your health information by alternative means or at alternative locations;


   Receive an accounting of certain disclosures made of your health information other than for payment, treatment, and healthcare operations; and,


   Receive notification pursuant to the law if there is a breach of unsecured protected health information.


If you would like to make a request for restrictions, a paper copy of this Notice, amendments to a health record, confidential communications of your health information, or an accounting of your health information disclosures, you must submit your request in writing to our Privacy Officer at Wild Rose Community Memorial Hospital located at PO Box 243 in Wild Rose, Wisconsin, 54984.


More information regarding disclosures and your health care rights may be found in 45 C.F.R. (Code of Federal Register).




If you believe your privacy rights have been violated, you may file a complaint with the WRCMH Privacy Officer at Wild Rose Community Memorial Hospital located at PO Box 243 in Wild Rose, Wisconsin, 54984. We request that you file your complaint in writing so that we may better assist in the investigation of your complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services. There will be no retaliation against you in any way for filing a complaint.


WRCMH is required by law to maintain the privacy of, and provide individuals with, this Notice of our legal duties and privacy practices with respect to protected health information. WRCMH reserves the right to change the terms of this Notice and will notify you of such changes at your following appointment and have updated Notices onsite and on the WRCMH website. If you have questions in reference to this Notice, please contact the WRCMH Privacy Officer at 920-622-5585.


References: Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. §§ 160 and 164 as modified 78 Fed. Reg. 5565, Jan. 25, 2013; HIPAA COW


S765-124 (09/13)