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.
Fort HealthCare, Inc. at 611 Sherman Ave, E, Fort Atkinson, WI, must maintain the privacy of your personal health information and give you this notice that describes our legal duties and privacy practices concerning your personal health information.
This notice describes the privacy practices of Fort HealthCare, including Fort Memorial Hospital, Fort HealthCare Behavioral Health Center, the Fort HealthCare clinics in Cambridge, Fort Atkinson, Edgerton, Elkhorn, Jefferson, Johnson Creek, Lake Mills, and Whitewater, UW Cancer Center – Johnson Creek, and certain other providers with which Fort HealthCare has a Joint Notice Agreement. These organizations are participants in Fort HealthCare’s organized health care arrangement. Each Fort HealthCare entity maintains an individual medical record for each patient, however, information may be shared between the entities when permitted under this Notice or otherwise by law.
The privacy requirements in this notice apply to all individuals authorized by law to access your health records, including each of the above entities’ employees, staff, volunteers and other workforce members, and the physicians and allied health professionals on the hospital’s medical staff. Note that not all entities have volunteers or medical staff members; for example, the Fort Healthcare Behavioral Health Center does not have any volunteers.
In general, when we release your health information, we must release only the information we need to achieve the purpose of the use or disclosure. However, all of your personal health information that you designate will be available for release if you sign an authorization form, if you request the information for yourself, to a provider regarding your treatment, or due to a legal requirement. We must follow the privacy practices described in this notice. We reserve the right to change the privacy practices described in this notice, in accordance with the law. Changes to our privacy practices would apply to all health information we maintain. Any changes to our privacy practices will be posted on our website, www.FortHealthCare.com, before we make any such change.
The law permits us to use or disclose your health information for only the following, limited purposes:
Treatment. We may use or disclose your health information to a physician or other healthcare provider furnishing treatment to you. For example, your doctor will use the information in your medical record to determine which treatment option, such as a drug or surgery, best addresses your health needs. The treatment selected will be documented in your medical record, so your other health care professionals can make informed decisions about your care.
Payment. We may use and disclose your protected health information to obtain payment for services we provide to you. In order for an insurance company to pay for your treatment, we must submit a bill that identifies you, your diagnosis, and the treatment provided to you. As a result, we will pass such health information onto an insurer in order to help receive payment for your medical bills.
Health Care Operations. We may use and disclose your health information in connection with our health care operations. For example, we may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care we deliver. These quality and cost improvement activities may include evaluating the performance of your doctors, nurses and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to patients in similar situations.
Notwithstanding any disclosures that are described above, we may need to obtain your written authorization to disclose confidential health information or information from your mental health treatment records.
Appointment Reminders. Unless you provide us with alternative instructions, we may use and disclose your health information for appointment reminders. For example, we may look at your medical record to determine the date and time of your next appointment with us, and then send you a reminder letter to help you remember the appointment.
Marketing. Unless you tell us you do not want to receive this information, we may look at your medical information and decide that another treatment or a new service we offer may interest you. For example, we may contact cancer patients to notify them that we have a new cancer research facility that offers new life-saving treatments.
Fundraising. We may use information found in your medical record, such as your name, address, phone number, and treatment dates, to contact you for our fund-raising purposes. For example, in order to provide more charity care or otherwise improve the health of your community, we may want to raise additional money and therefore may contact you for a donation. We will provide you with any fundraising materials and a description of how you may opt out of receiving future fundraising communications.
We will not conduct fundraising that is based on information from any mental health treatment records.
Business Associates. We may share your health information with third party “business associates” with whom we contract to assist us in health care operations, treatment, or payment activities. Our business associates will be required to protect your health information in accordance with this notice and as required of us by law.
As Required Or Permitted By Law. Sometimes we must report some of your health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
For Public Health And Benefit Activities. We are required by state and federal laws to report some limited health information to authorities to help prevent or control disease, injury, or disability. For example, we must report diseases like cancer, injuries like gun shot wounds, birth and death information, information of concern to the Food and Drug Administration, or information related to child abuse or neglect.
We may have to report certain illnesses and injuries relating to environmental conditions to your employer, so that your workplace environment can be monitored for safety.
We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline, or license those who work in the health care system or for government benefit programs.
We may disclose your health information to coroners, medical examiners, and funeral directors, to carry out duties related to your death such as identifying the body, determining cause of death, preparing for your funeral.
If you or your family members have indicated a willingness to donate your organs, in the rare instance that the situation may occur, we may disclose your health information to people involved with obtaining, storing, or transplanting organs, eyes, or tissue of cadavers for donation purposes.
We may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public’s health or safety.
If you are involved with military, national security or intelligence activities, are in the custody of law enforcement officials, or an inmate in a correctional institution, we may be required to disclose your health information to the proper authorities so they may carry out their duties under the law.
We may disclose your health information to the appropriate persons in order to comply with the laws related to workers’ compensation or other similar programs. These programs may provide benefits for work-related injuries or illness.
Notwithstanding any disclosures that are described above, we will not disclose mental health or drug treatment records or certain confidential treatment information for some of the activities under this section without your written authorization, unless we are required to do so by law.
Research. Under certain circumstances, and only after a special approval process by a review board, we may use and disclose your health information to help conduct research. The review board may approve using your health information without your written authorization when the board determines that the researcher will follow all privacy rules in order to prevent an possibility of your identification. Such research might try to find out whether a certain treatment is effective in curing an illness.
Notwithstanding any disclosures that are described above, no research will be conducted using mental health or drug treatment records.
Hospital Directory. With your permission, if you are inpatient in the hospital we will include your name, location in our facility, your general health condition (e.g., “stable”, or “unstable”), and your religious affiliation in the hospital’s directory and will tell this information to people who call or visit at the hospital and ask for you by name. However, the information about your religious affiliation will only be disclosed to clergy.
Your presence as an inpatient in the hospital will not be disclosed if your admission is for behavioral, mental health or drug treatment, as this disclosure is prohibited by law.
To Those Involved With Your Care Or Payment Of Your Care. Unless you tell us otherwise in writing, if your family members, relatives, or friends are helping to care for you or pay your medical bills we may disclose your health information to those people. We will disclose only information that is relevant to that person’s involvement. We may also use our professional judgment to allow a person to pick up prescriptions, medical supplies, x-rays or other health information on your behalf. In addition, we may disclose your health information to organizations authorized to handle disaster relief efforts, so those who care for you can receive information about your location or health.
When Required By Law. We may disclose your health information when required by law to do so or in the course of certain legal proceedings. For example, we may disclose your information in response to a Wisconsin court order.
NOTE: Except for the situations listed above, we must obtain your specific written authorization for any other disclosure of your health information. If you sign a form authorizing us to release our health information, you may withdraw your authorization at any time (except to the extent we have relied upon it), as long as your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to Debra S. White, Privacy Officer, at 920-568-5180.
Your Health Information Rights
You have several rights with regard to your health information. If you wish to exercise any of the following rights, send your written request to Debra S.White, Privacy Officer, at Fort HealthCare. Specifically, you have the right to:
Inspect and copy your health information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. However, this right does not apply to psychotherapy notes or information gathered for judicial proceedings, for example. In addition, we may charge you a reasonable fee if you want a copy of your health information.
Request to correct your health information. If you believe your health information is incorrect, you may ask us to correct the information. You will be asked to make such requests in writing and to give a reason as to why your health information is incorrect. This request will become a part of your medical record. However, if we did not create the health information that you believe is incorrect, or if your treating physician disagrees with you and believe your health information is correct, we may deny your request.
Request restrictions on certain uses and disclosures. You have the right ask for restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities. Or, you may want to limit the health information provided to family or friends involved in your care or payment of medical bills. You may also want to limit the health information provided to authorities involved with disaster relief efforts. However, we are not required to agree in all circumstances to your requested restriction.
If you receive certain medical devices (for example, life-supporting devices used outside our facility), you may refuse to release your name, address, telephone number, social security number or other identifying information for purpose of tracking the medical device.
As applicable, receive confidential communication of health information. You have the right to ask that we communicate your health information to you in different ways or places. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address. We must accommodate reasonable requests.
Receive a record of disclosures of your health information. You have the right to ask for a list of the disclosures of your health information we have made during the previous six years, but the request cannot include dates before April 14, 2003. This list will include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request more than one list per year. The list will not include disclosures made to you, or for purposes of treatment, payment, health care operations, our directory, national security, law enforcement, and health oversight activities.
Obtain A Paper Copy Of This Notice. You may receive a paper copy of this notice at any time upon your request, even if you earlier agreed to receive this notice electronically. A copy of our current privacy notice may be viewed on our web site by visiting www.FortHealthCare.com.
Questions and Concerns. If you want more information about our privacy practices or have any questions on concerns, please contact us. If you are concerned that we may have violated your privacy rights, you may file a complaint with us and with the Department of Health and Human Services Office for Civil Rights, Region X. We will not retaliate against you for filing such a complaint. To file a complaint with Fort HealthCare, please contact Debra S. White, Privacy Officer, at 920-568-5180 or write to her at HIM Department, 611 Sherman Avenue East, Fort Atkinson, WI 53538. If you choose to contact the Department of Civil Right, you may do so by writing to Region X Office for Civil Rights, US Department of Health and Human Services, 2201-6th Ave., M/S RX-11, Seattle, WA, 98121-1831 or http://hhs.gov/ocr
Again, if you have any questions or concerns regarding your privacy rights or the information in this notice, please contact Debra S. White, Privacy Officer, at 920-568-5180.
This Notice of Medical Information Privacy is Effective April 14, 2003.
Revision Date: February 1, 2007. Revision Date: April 6, 2010.