611 Sherman Avenue East
Fort Atkinson, WI 53538
(920) 568-5000
La linea de mensajes: (920) 568-5001



Fort HealthCare, Inc. will maintain the privacy of your personal health information. This Notice of Privacy Practices describes our legal duties and privacy practices concerning your personal health information.

This Notice describes the privacy practices of Fort HealthCare, Inc., including: Fort Memorial Hospital; Fort HealthCare Behavioral Health Center; the Fort HealthCare clinics, 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, Inc. entity maintains an individual medical record for each patient. Health Information may be shared between these entities when permitted under this Notice or otherwise by law.

The privacy requirements in this Notice apply to Fort HealthCare and each of the above entities’ employees, staff, volunteers and other workforce members, as well as the physicians and allied health professionals on the hospital’s medical staff.

In general, when we release your health information, we will release only the information we need to achieve the purpose of the use or disclosure. If you sign an authorization form or if you request the information for yourself, all of the personal health information that you designate will be available for release. A health care provider will have broad access to your health care information for treatment purposes. And, when there is a legal requirement that we disclose health information, we will disclose all the information that we are legally required to provide.

We will 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. Any changes to our privacy practices will be posted on our website: www.FortHealthCare.com.

The law permits us to use or disclose your health information for the following limited purposes:

Treatment. We may use or disclose your health information to a physician or other health care 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 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 on to an insurer in order to help receive payment for your medical bills.

If you have paid us out of pocket for health care services, you may request that we do not share information about that specific care with your health plan. Disclosures to your health plan made prior to your request and disclosures to your health plan for any subsequent care will not be affected.

Health Care Operations. We may use and disclose your health information in connection with our health care operations. For example, we may use information from patient health records in order to improve the quality or cost of care we deliver. These quality and cost improvement activities may include evaluating the performance of doctors, nurses, and other health care professionals, or examining the effectiveness of the treatment provided to our patients.

Appointment Reminders. Unless you tell us otherwise, 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 call or send you a reminder letter to help you remember or prepare for the appointment.

Business Associates. We may share your health information with third party “business associates” with whom we contract to assist us in treatment, payment, or health care operations activities. Our business associates are required to protect your health information in accordance with this Notice and as required by law.

Hospital Directory. If you are an inpatient in the hospital, unless you object, we will include your name, location in our facility, and your general health condition (e.g., “stable”, or “unstable”) in the hospital’s directory and will share this information with people who call or visit at the hospital and ask for you by name. If you indicate your religious affiliation with us, we may disclose this information to a member of the clergy.

To Those Involved With Your Care or Payment of Your Care.  Unless you tell us otherwise in writing, if you have a family member, relative, or a friend who is helping to care for you or pay your medical bills, we may disclose your health information to these persons.  We will disclose only information that is relevant to that person’s involvement.  We will use our professional judgment in allowing another 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.

As Required or Permitted By Law. We may disclose health information to legal authorities, such as law enforcement officials, court officials, or government agencies, when necessary. For example, we are required by law to report suspected child abuse or neglect and certain physical injuries, such as gunshot wounds, significant burns, or injuries that appear to be a result of a crime. We may also report incidents involving the abuse or neglect of an adult. We may be required to disclose health information in response 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 certain diseases, such as cancer; birth and death information; and information of concern to the Food and Drug Administration.

We may 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 health information to governmental authorities so they can monitor, investigate, inspect, discipline, or license health care workers or for compliance with government benefit programs.

If you are an organ donor, we may disclose health information to organizations involved with obtaining, storing, or transplanting organs, eyes, or tissue.

We may release your health information to the proper authorities if we believe, in good faith, that the release is necessary to prevent or minimize a serious and approaching threat to the health or safety of you, another individual, or the public.

If you are involved with military, national security or intelligence activities; are in the custody of law enforcement officials; or are 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.

Research. Under certain circumstances, and only after a special approval process by a review board, we may use and disclose your health information to 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 a possibility of your identification. Research is important to find out whether certain treatments are effective in curing an illness.

Marketing. Unless you object, we may use your health information to inform you of products or services that we believe may be of interest to you. For example, we might contact patients receiving cancer treatment to notify them of the availability of an innovative treatment.

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 fundraising purposes. For example, to provide more charity care or otherwise improve the health of this community, we may attempt to raise money; therefore, we may contact you to invite you to attend an event or to ask you for a donation. If we send you any fundraising materials, we will tell you how you may opt out of receiving future fundraising communications.

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 valid court order.

Except for the situations listed above, we must obtain your specific written authorization for any other use or disclosure of your health information. This includes marketing activities conducted by third parties or where a third party seeks to purchase protected health information. If you authorize release of your health information, you may withdraw your authorization at any time, if you submit a written notification to Debra S. White, Privacy Officer, Fort HealthCare HIM Department, 611 Sherman Avenue East, Fort Atkinson, WI 53538.

Mental Health Treatment

Generally, the use or disclosure of psychotherapy notes requires the authorization of the patient. Further, Wisconsin law is more protective than HIPAA of certain types of health information, including information about a person’s mental health and alcohol or drug treatment. We will only use or disclose information about a patient’s mental health treatment or alcohol or drug treatment as permitted or required by law, or as authorized by the patient.

We will not use or disclose information from a patient’s mental health record for directory purposes or fundraising. We would only use information for a research study with the authorization of the patient.

Your Health Information Rights

You have important rights with regard to your health information. Please contact our Privacy Officer if you would like additional information or would like to exercise any of the following rights:

Inspect and Copy Your Health Information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. You also have the right to request an electronic copy of your health information. We may charge you a reasonable fee for a copy of your health information. This right does not apply to psychotherapy notes or information gathered for judicial proceedings.

Request a Correction of 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 explain why you believe your health information is incorrect. This request will become a part of your medical record. If we did not create the health information that you believe is incorrect, or if your treating physician determines that 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. For example, you may want to limit the health information provided to a family member involved in your care or payment of medical bills, so that they are not informed about a certain diagnosis. We are not required to agree in all circumstances to your requested restriction, but we will make reasonable efforts to do so.

If you receive certain medical devices (e.g., life-supporting devices used outside our facility), you may object to the release of your identifying information for purposes 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 a specific manner. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to an alternate address. We will accommodate reasonable requests.

Receive a Record of Disclosures of Your Health Information. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures of your health information we have made to others. 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. 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. You may indicate the time period you are requesting, which may be any period during the previous six years. We will not charge you for the list, unless you request more than one list in a twelve-month period.

Obtain a Paper Copy of This Notice. You may receive a paper copy of this Notice at any time upon your request. A copy of our current Notice of Privacy Practices may be viewed on our web site: www.FortHealthCare.com.

Notification of Breach.  If there should be a breach of your unsecured health information, we will notify you in a timely manner.

Questions and Concerns. If you want more information about our privacy practices or have any questions or concerns, or if you are concerned that we may have violated your privacy rights, you may file a complaint with us by contacting:

Debra S. White, Privacy Officer

Phone: 920-568-5180

Fort HealthCare HIM Department

611 Sherman Avenue East

Fort Atkinson, WI 53538

We will not retaliate against you for filing a complaint.

You may also file a complaint with the United States Department of Health and Human Services by contacting the HHS Office for Civil Rights, 233 North Michigan Ave, Suite 240 Chicago, IL 60601 or http://hhs.gov.ocr.

This Notice of Medical Information Privacy is Effective April 14, 2003.

Revision Date:  February 1, 2007.

Revision Date:  April 6, 2010.

Revision Date:  March 28, 2013.