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

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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.


Fort HealthCare, Inc. will maintain the privacy of your personal health information. This Notice of Privacy Practices describes the legal duties and 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 entities are participants in Fort HealthCare’s organized health care arrangement and will share information with each other, as necessary, to carry out treatment, payment, and health care operations (as discussed below) related to the 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. 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, a doctor treating you for an injury asks another doctor about your overall health condition.

Payment. We may use and disclose your health information to bill and get payment from health plans or other entities. For example, we give information about you to your health insurance plan so it will pay for your services.

Health Care Operations. We may use and disclose your health information in connection with our health care operations. For example, we use health information about you to manage your treatment and services.

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 are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. 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 your health information when required by law to do so or in the course of certain legal proceedings. 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 share your information in a disaster relief situation. We may report certain illnesses and injuries relating to environmental conditions to your employer, so that your workplace environment can be monitored for safety.

Medical Examiner or Funeral Director. We may share health information to a coroner, medical examiner, or funeral director when an individual dies.

Organ and Tissue Donation Requests. We may share health information about you with organ procurement organizations.

Workers’ Compensation, Law Enforcement and Other Government Requests. We may disclose health information to government authorities for health oversight activities authorized by law. 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 contact you to invite you to attend an event. If we send you any fundraising communications, you can tell us not to contact you again.

Health Information Exchange: We may participate in one or more health information exchanges (HIEs) whereby we may share your health information with other health care providers participating in the HIEs for treatment, payment, and health care operation purposes. A HIE is a system that electronically moves and exchanges health information between participating health care providers who have been approved to use the system. It allows your providers to access information about care you received elsewhere to, among other things, make sure the treatment they give you does not interact negatively with other treatments you may be receiving. Your health information is available to authorized health care providers through HIEs unless you decline to participate or “opt out” by completing our Health Information Exchange Patient Option  Form. If you previously submitted a Health Information Exchange Patient Option  Form to opt-out of HIEs and would now like to begin having your information shared, you may complete our Health Information Exchange Patient Option Form and indicate your desire to have your information shared. Please contact a Fort HealthCare reception staff person to change your participation preference or to request additional information.

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 our Privacy Officer, Fort HealthCare HIM Department, 611 Sherman Avenue East, Fort Atkinson, WI 53538.

Other Protections

Generally, the use or disclosure of psychotherapy notes requires the authorization of the patient. Further, Wisconsin and other federal law is more protective than HIPAA of certain types of health information, including information about a person’s mental health care, HIV/AIDS test results, and alcohol or drug abuse treatment. We will only use or disclose such information as permitted or required by applicable law, or as authorized by you, and we will not use or disclose such information for directory purposes or fundraising.

Your Health Information Rights

You have important rights with regard to your health information. We are required by law to maintain the privacy of your health information, to provide you with notice of our legal duties and privacy practices with respect to your health information, and notify you following a breach of unsecured health information.

Inspect and Copy Your Health Information. With a few exceptions, you have the right to inspect and obtain a copy of your health information in paper or readily producible electronic form. You will be asked to make such requests in writing; in certain circumstances we may ask you to use our form to process your request. If you would like us to transmit your health information to another person or entity, your written request must be signed and clearly identify the designated recipient and where to send the health information. We may charge you a reasonable, cost-based fee for a copy of your health information. Please contact our Privacy Officer for an approximate fee that may be charged for a copy of your health information. This right does not apply to psychotherapy notes, information gathered for judicial proceedings, information that is not used to make decisions about you, and other information that in a physician’s professional judgment could endanger the life or safety of you or another person.

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, if your treating physician determines that your health information is correct, or if the information is not used to make decisions about you, we may deny your request.

Request Restrictions on Certain Uses and Disclosures. You have the right to 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 to your requested restriction in all circumstances, but we will make reasonable efforts to accommodate your requests that do not affect your care. 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.

If you pay for a service or health care item out-of-pocket in full, you may ask use not to share that information with your insurer for the purpose of payment or our operations. Disclosures to your insurer made prior to your request and disclosures to your insurer for any subsequent care will not be affected.

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. You will be asked to make requests for confidential communications in writing. 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 as specifically authorized by you; to persons involved in your care; older than six years; incident to an otherwise permitted use or disclosure; 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. 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 may be viewed on our web site: http://www.forthealthcare.com We are required to abide by the terms of our Notice currently in effect. We reserve the right to change the terms of our Notice and make the new notice provisions effective for all health information that we maintain. The new Notice will be available upon request, in our facilities, and on our website.

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:

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.
Revision Date: November 23, 2016

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