Joint Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Please Review This Notice Carefully
Esta información está disponible en español. Si necesita una copia en español, pídala a un miembro del personal. (This information is available in Spanish. Please ask a staff member if you need a copy in Spanish.)
This Notice applies to all patient health information maintained by Froedtert Hospital or the Medical College of Wisconsin for services provided either at the Hospital's main facility located at 9200 W. Wisconsin Ave,, Wauwatosa, Wisconsin; or at clinics, outpatient or other treatment facilities operated by Froedtert Hospital and the Medical College of Wisconsin. If you have questions after reading this Notice, please contact the Hospital's Privacy Officer.
Our Pledge Regarding Your Health Information
We are committed to the protection of patient health information in accordance with applicable law and accreditation standards regarding patient privacy. The health information about you is personal. A record of the care and services you receive at Froedtert Hospital and the Medical College of Wisconsin and the affiliated clinics is needed to provide you with quality care and to comply with legal requirements.
The law requires us to:
Protected Health Information (PHI) is any information, whether oral, written, electronic, magnetic or recorded in any form that is received by the hospital or college as a health care provider. PHI as identified by HIPAA is, your name, address, zip code, geographical codes, employers, your relatives names, date of birth, telephone and fax number, email address, SSN, insurance information, medical record number, member or account number, certificate numbers, voice prints or finger prints, photos or any other unique identifying numbers, characteristics or codes.
IN CERTAIN CIRCUMSTANCES WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU WITHOUT YOUR WRITTEN CONSENT
- For Treatment: We will use health information about you to provide you with medical treatment or services. We will disclose health information about you to doctors, residents, nurses, technicians, students in healthcare training programs, or other Hospital or College personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes might slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the Hospital or College also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose health information about you to people outside the Hospital and College who provide your medical care after you leave the Hospital. For example, a doctor or nursing home that provides your care following your hospital service will be provided information about your care and treatment.
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For Payment: The Hospital and the College will use and disclose your health information to send bills and collect payment from you, your insurance company, or other payers, such as Medicare. We will do this for the care, treatment and other related services you receive from the Hospital or the College. We may also provide your name, address and insurance information to other care providers related to your care at the Hospital. We may also tell your health insurer about a treatment your doctor has recommended in order to obtain prior approval to determine whether your plan will cover the treatment.
- For Healthcare Operations: We may use and disclose health information about you for Hospital and the College business operations. These uses and disclosures are necessary to operate the Hospital and the College and make sure that all of our patients receive quality care and cost effective services. For example, we may use health information to review the quality of our treatment and services, and to evaluate the performance of our staff and students in caring for you. When we use or disclose your healthcare information, it may be to another organization that assists us in operating our Hospital or College clinics. For example, when your doctor dictates a summary of his visit with you, an outside company types up the document for our medical records. These outside agencies who are called "business associates," have contracted with us to keep any healthcare information received from us confidential in the same way we do.
- Hospital Directory: When you are an inpatient, the Hospital may list certain information about you such as your name, where you are in the Hospital, and your religious affiliation in a Hospital directory. The Hospital can disclose this information, except for your religious affiliation, to people who ask for you by name. Your religious affiliation may be given to members of the clergy even if they do not ask for you by name. You may request that no information contained in the directory be disclosed. To restrict use of information listed in the directory, please inform the admitting staff or your nurse. They will assist you in this request.
- Fundraising/Marketing Activities: The Hospital and the College, may use health information such as your name, address, phone number and the dates you received treatment at the Hospital or the College to contact you to raise money for the organization. The Hospital or the College may share this information with a foundation associated with the Hospital or the College to work in our behalf. An example of this would be mailers to all patients regarding a walk or run for breast cancer. This same health information may be used to develop new programs as part of promoting health. This is so that we may provide you general health information, information about new programs, or the Hospital or College newsletter. If you do not want the Hospital to contact you for our fundraising and or marketing efforts, you must notify us in writing. Please contact our Privacy Officer to help you with this request.
- Appointments: The Hospital or College may contact you for reminders of appointments and/or information necessary for your appointment.
Public Health and Government Functions: The Hospital or the College will disclose your health information in certain circumstances to:
- Control or prevent a communicable disease, injury or disability, to report births and deaths, and for public health oversight activities or interventions.
The Food and Drug Agency (FDA), to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law.
To a state or federal government agency to facilitate their functions.
- Required or Permitted by Law: The Hospital and College are required or permitted to release your health information as it relates to:
- Suspected elder or child abuse law enforcement agencies responsible to investigate or prosecute abuse.
A valid court order.
The Department of Health and Family Services (DHFS), a protection or advocacy agency or law enforcement authorities investigating abuse, neglect, physical injury, death, violent crimes such as suspicious wounds, burns, gunshot wounds and death.
Your court appointed guardian or agent you have appointed under a health care power of attorney.
A prisoner's healthcare provider.
- Research: The Hospital and College may use and share your health information for certain kinds of research. The Hospital and College have a research review board that reviews and approves research projects. 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. Other research projects submitted to the review board that include information identifying you with your health information will require your written authorization to use the information before the research begins. If you choose not to participate in a research project your care and treatment will not be affected.
- Workers' Compensation: The Hospital or College may release your health information as it relates to your work injury or illness for workers' compensation. This program provides benefits for work-related injuries or illness.
In all instances where we deal with your protected health information, the Hospital and the Medical College of Wisconsin follow a "Minimum Necessary" standard whereby all staff are required to make every reasonable effort to limit the use, the disclosure of, and requests of your health information to accomplish the intended purpose or job.
Your Health Information Rights
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Right to Request Restrictions: You have the right to request certain restrictions of the Hospital's and the College's use or disclosure of health information for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your health information to someone who is involved in your care or the payment for your care. The Hospital and the College are not required to agree to your request if it interferes with patient care, treatment, hospital/clinic operations, and/or payment of your bill. If the Hospital or the College agrees to the restriction, it will comply with your request unless the information is needed to provide you emergency treatment. A request for restriction should be made in writing. To request a restriction you must complete a request form that is available in Patient Care areas or in the Medical Records Department.
- Right to Inspect and Copy: You have the right to inspect and receive a copy of your health records. While an inpatient, a request to inspect your records may be made to your nurse, doctor or while an outpatient to the Medical Records Department. For copies of your health information, requests must go the Medical Records Department. For billing information, contact the Patient Financial Services.
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Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information, for as long as the Hospital or the College maintains the information. Requests for amending your health information should be made to the Medical Records Department. The Hospital or the College, whichever one maintains the information, will respond to your request within 60 days after you submit the written amendment request form.
- Right to a List of Disclosures: You have the right to request a list of disclosures we have made of your health information. For example, we may have shared health information with a nursing home when making arrangements for placement. To request this list of disclosures, you must submit your request in writing to our Medical Records Department. The first list you request from each organization within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
- Right to Alternate means of Communication: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate all reasonable requests.
- Right to Revoke Authorization: Uses and disclosures of health information not covered by this Notice or the laws that apply to the Hospital and the College will be made only with your authorization. If you authorize the Hospital or College to use or disclose your health information, you may revoke that authorization, in writing at anytime. We are unable to take back any disclosures we have already made with your permission. To revoke an authorization you must contact the Medical Record Department at Froedtert and/or the College.
- Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with the Hospital, the College or with the Department of Health and Human Services. To file a complaint with the Hospital and or the College, please contact the Privacy Officer. All complaints must be made in writing. This person will assist you in filing your complaint and the necessary paper work. Filing a complaint will not affect your care and treatment.
Important Note: We reserve the right to revise or change this Notice. Each time you register at a site covered by this Notice for health care services, the most current copy of this notice will be available for you.
How to Contact Us
Froedtert Privacy Officer: 414-805-2895
College Privacy Questions: 414-805-5514
Medical Records Department
Froedtert Hospital: 414-805-2909
Medical College of Wisconsin: 414-805-5070
Patient Financial Services
Froedtert Hospital: 414-805-5951
Medical College Of Wisconsin Billing: 414-456-4511
Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Voice Phone 312-886-2359
FAX 312-886-1807
TDD 312-353-5693
E-mail: OCRPrivacy@hhs.gov
For more information about filing a health information privacy complaint with the Office for Civil Rights, please visit this Web page:
http://www.hhs.gov/ocr/privacyhowtofile.htm
Effective Date: April 14, 2003
Item #: 37974 (1/06)