Please Review This Notice Carefully

Esta información está disponible en español. (This information is available in Spanish.)

This notice applies to all protected health information (“PHI”) maintained by The Medical College of Wisconsin (“MCW”) and Froedtert Health affiliates: Froedtert Memorial Lutheran Hospital, Inc.; Community Memorial Hospital of Menomonee Falls, Inc.; St. Joseph’s Community Hospital of West Bend, Inc.; Froedtert & the Medical College of Wisconsin Community Physicians, Inc. (“FMCWCP”); West Bend Surgery Center, LLC; Froedtert Surgery Center, LLC; Waukesha Surgery Center, LLC; and any other affiliate Froedtert Health designates as part of its affiliated covered entity for purposes of HIPAA for services provided at any main facility, clinic, outpatient facility or other location, including employer sponsored services provided at your employment site.  The term “Froedtert Health Affiliates” in this notice includes MCW and all of the Froedtert Health affiliate organizations listed above.  This notice will be followed by all members of our workforce, including employees, medical staff members, students and volunteers with respect to PHI maintained by the Froedtert Health Affiliates.  The Froedtert Health Affiliates may share PHI with each other for treatment, payment or health care operations purposes described in this Notice. If you have any questions after reading this Notice, please contact the Privacy Officer or designee.

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. This information may consist of paper, digital or electronic records but could also include photographs, videos and other electronic transmissions or recordings that are created during your care and treatment. A record of the care and services you receive is needed to provide you with quality care and to comply with legal requirements.

The law requires us to:

  • Make sure that health information that identifies you is kept private.
  • Give you this Notice of our legal duties and privacy practices with respect to health information about you.
  • Notify you in the event of a breach of your unsecured PHI.
  • Follow the terms of this Notice that are currently in effect.

* Protected Health Information (PHI) is any individually identifiable health information, whether oral, written, electronic, transmitted or maintained in any form or medium that is created or received by a health care provider, a health plan, or a health care clearinghouse; and relates to an individual’s past, present, or future physical or mental health condition, health care treatment, or the past, present or future payment for health care services to the individual; and either identifies an individual (for example, name, social security number or medical record number) or can reasonably be used to find out the person’s identity (address, telephone number, birth date, e-mail address, and names of relatives or employers).

When releasing your PHI, the FH Affiliates will follow a “Minimum Necessary” standard, whereby we will make reasonable efforts to limit the use and disclosure of your PHI in order to accomplish the intended purpose or job.

Uses and disclosures of health information not covered by this Notice or the laws that apply to the FH Affiliate will be made only with your authorization.

In Certain Circumstances We May Use And Disclose PHI 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 PHI about you to doctors, residents, nurses, technicians, students in health care training programs, or other 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 Froedtert Health Affiliate may share health information about you in order to coordinate the services you need, such as prescriptions, lab work and x-rays. We may disclose health information about you to people outside the Froedtert Health Affiliate who provide your medical care. For example, we may provide information about your care and treatment to a doctor or nursing home that provides your care following your hospital or clinic services. 
  • For Payment: We will use and disclose your PHI to send bills and collect payment from you, your insurance company, or other payers, such as Medicare, for the care, treatment, and other related services you receive. We may provide your name, address and insurance information to other health care providers related to your care. We may tell your health insurer about a treatment your doctor has recommended to obtain prior approval to determine whether your plan will cover the cost of the treatment. For billing information, contact the Patient Financial Services Department.
  • For Health Care Operations: We may use and disclose PHI about you for the purpose of our business operations. These business uses and disclosures are necessary to make sure that our patients receive quality care and cost effective services. For example, we may use PHI to review the quality of our treatment and services, and to evaluate the performance of our staff, contracted employees and students in caring for you. We may use or disclose your PHI to an outside company that assists us in operating our hospital or clinic. For example, when your doctor dictates a summary of the visit with you, an outside company types up the document for our medical records. These outside companies are called “business associates”, who have contracted with us to keep any PHI received from us confidential in the same way we do.
  • Family Members and Friends: We may disclose PHI about you to a family member, relative, or another person identified by you who is involved in your health care or payment for your health care. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited PHI is in your best interest under the circumstances.
  • Hospital Directory: When you are an inpatient admitted to the hospital, or are admitted as an outpatient to the surgery center, the Froedtert Health Affiliate may list certain information about you, such as your name, your location in the hospital, and your religious affiliation in a hospital directory. The hospitals 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. In emergency circumstances, if you are unable to communicate your preference, you will be listed in the directory.
  • Fundraising Activities: We may use PHI, such as your name, address, phone number, the dates you received services, department of service information, treating physician, outcome information, and health insurance status to contact you to raise money for the Froedtert Health Affiliate. We may share this information with a foundation associated with the Froedtert Health Affiliate to work on its behalf. You have the right to opt out of receiving fundraising communications from us.
  • Future Communications: We may use your name, address, e-mail and phone number to contact you to provide you information about new programs or other services we offer, or the Froedtert Health Affiliate newsletters. An example of this would be mailers to all patients regarding a walk or run for breast cancer. This same information may be used to develop new programs as part of promoting health.
  • Public Health and Government Functions: We will disclose your PHI 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 Administration (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: We will disclose your PHI when required to do so by federal, state, or local law.  We are permitted, and required in some cases, to release your PHI in certain circumstances to:
    • Report suspected elder or child abuse to law enforcement or other governmental agencies responsible to investigate or prosecute abuse.
    • Respond to a valid court order.
    • The Department of Health Services (DHS), the Department of Children and Families (DCF), a protection or advocacy agency, law enforcement authorities investigating abuse, neglect, physical injury, death, and suspicious wounds, burns, or gunshot wounds.
    • Your court appointed guardian or agent you have appointed under a health care power of attorney.
    • A prisoner's health care provider.
    • A medical examiner, coroner, and funeral director regarding a death.
    • Law enforcement officials with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons.
  • Organ, Eye and Tissue Donation: We will disclose PHI to organizations that obtain, bank or transplant organs or tissues.
  • Research: A Froedtert Health Affiliate and MCW may use and share your health information for certain kinds of research. The Froedtert Health Affiliate and MCW 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 will require your written authorization to use the information before the research begins. Whether or not your health information is used in a research project, your care and treatment will not be affected.

  • Workers’ Compensation: We will disclose your health information that is reasonably related to a worker’s compensation illness or injury following written request by your employer, worker’s compensation insurer, or the Department of Workforce Development or its representative.

  • Employer Sponsored Health and Wellness Services: We maintain PHI about employer sponsored health and wellness services we provide our patients, including services provided at their employment site. We will use the PHI to provide you medical treatment or services and will disclose the information about you to others who provide you medical care. For employer sponsored services provided at your employment site, summary, de-identified information may be provided to your employer for planning purposes. If you wish to have detailed health information provided to your employer, you must complete an authorization for release of PHI.

  • Shared Medical Record/Health Information Exchanges: We maintain PHI about our patients in shared electronic medical records that allow the Froedtert Health Affiliates to share PHI. We also participate in various electronic health information exchanges that facilitate access to PHI by other health care providers who provide you care. For example, if you are admitted on an emergency basis to another hospital that participates in the health information exchange, the exchange will allow us to make your PHI available electronically to those who need it to treat you at the hospital.

Your Protected Health Information Rights

Right to Request Restrictions: You have the right to request certain restrictions of our use or disclosure of PHI for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care or the payment for your care. We are not required to agree to your request in most cases. If the Froedtert Health Affiliate agrees to the restriction, it will comply with your request unless the information is needed to provide you emergency treatment. We must, however, agree to your request to (1) restrict our disclosure of your PHI to your health plan when you have paid us out-of-pocket in full for the health care item or service we provided you, (2) restrict our disclosure of your immunization data to the Wisconsin Immunization Registry. A request for restriction should be made in writing. To request a restriction, please contact the Health Information/Medical Records Department.

Right to Inspect and Copy: You have the right to inspect and receive a copy of PHI about you that may be used to make decisions about your health. A request to inspect your records may be made to your nurse or doctor while you are an inpatient or to the Health Information/ Medical Records Department while an outpatient. For copies of your PHI, requests must go to the Health Information/ Medical Records Department. There may be a charge for these copies. For copies of billing records, you may contact Patient Financial Services.

Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information, for as long as the Froedtert Health Affiliate maintains the information. Requests for amending your PHI should be made to the Health Information/Medical Records Department. The Froedtert Health Affiliate that maintains the information will respond to your request within 60 days after you submit the written amendment request form. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Right to a List of Disclosures: You have the right to request a list of instances in which we or our business associates disclosed your PHI for purposes other than treatment, payment, health care operations, disclosures authorized by you or made to you, and certain other activities. To request this list of disclosures, you must submit your request in writing to the designated Health Information/Medical Records Department. The first list you request from each Froedtert Health Affiliate 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 Request Alternate Means of Communication: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location. We will accommodate all reasonable requests. You must make any such request in writing submitted to the Privacy Officer or designee.

Right to Require Authorization: Your authorization is required for most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI.

Right to Revoke Authorization: If you authorize the Froedtert Health Affiliates to use or disclose your PHI, you may revoke that authorization, in writing, at any time. We are unable to take back any disclosures we have already made with your permission. To revoke an authorization you must contact the designated Health Information/Medical Record Department.

Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with the relevant Froedtert Health Affiliate or with the Secretary of the Department of Health and Human Services. To file a complaint with a Froedtert Health Affiliate, you must put your complaint in writing and address it to the designated Privacy Officer or delegate. 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 Notice: We reserve the right to revise or change this Notice and to make the new Notice provisions effective for all PHI the Froedtert Health Affiliates maintain. Each time you register for health care services at a site covered by this Notice, the most current copy of this Notice will be available for you. You have a right to obtain a paper copy of this Notice upon request.

How to Contact Us

Privacy Officer:
Froedtert Health 414-805-2895
9200 W. Wisconsin Avenue, Wauwatosa,WI 53226

Medical College of Wisconsin 1-844-703-8171
8701 Watertown Plank Rd, Wauwatosa, WI 53226

Health Information/Medical Records Department
Froedtert Health 262-836-2510
Medical College of Wisconsin 262-836-2510

Patient Financial Services 
Froedtert Health 800-466-9670
Medical College of Wisconsin 800-242-1649

Web sites
Froedtert Health 
Medical College of Wisconsin

How to Contact the Office for Civil Rights, Region V:
Office for Civil Rights, Region V
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Voice Phone 800-368-1019
FAX 202-619-3818
TTD 800-537-7697

Effective Date: April 14, 2003
Last Revision Date: Oct. 25, 2019
Item #: 37974 (supersedes 10/16, 06/16, 05/15, 07/13, 03/12, 09/10, 04/10, 07/09)

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