Back to Records or Forms

Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities

This Notice describes how medical information about you may be used and disclosed and how you can access your information. Please review it carefully.

This Notice describes the privacy practices of Western Wisconsin Health.

Health Care Providers Covered By This Notice

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan, and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer.

How We May Use or Disclose Your Health Information: Western Wisconsin Health collects health information about you and stores it in a chart and in an electronic health record. This is your medical record. The medical record is the property of Western Wisconsin Health, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

Treatment: We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide service we do not provide. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test.

Payment: We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.

Health Care Operations: We may use and disclose medical information about you to operate Western Wisconsin Health. For example, we may use and disclose this information to review and improve the quality of care we provide. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection, compliance programs, business planning and management. We may also share your medical information with our “business associates.” We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information, to help them with their quality assessment and improvement activities, patient-safety activities, population-based efforts to improve health or reduce health care costs, protocol development, case management or care-coordination activities, review of competence qualifications and performance of health care professionals, training programs, accreditation, certification or licensing activities, or health care fraud and abuse detection and compliance efforts.

Appointment Reminders: We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

Notification and Communication With Family: We may use your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

Marketing: Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by Western Wisconsin Health and tell you which health plans we participate in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we received any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.

Required by Law: As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or response to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

Public Health: We may, and are sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly, unless in our best professional judgment we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

Health Oversight Activities: We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitation imposed by law.

Judicial and Administrative Proceedings: We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressing authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

Law Enforcement: We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.

Coroners: We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.

Organ or Tissue Donation: We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

Public Safety: We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health and safety of a particular person or the general public.

Proof of Immunization: We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf of yourself or your dependent.

Specialized Government Functions: We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

Workers’ Compensation: We may disclose your health information as necessary to comply with workers’ compensation laws. For example, to the extent your care is covered by workers’ compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers’ compensation carrier.

Breach Notification In the case of a breach of unsecured protected health information, we will notify you as required by law. In some circumstances, our business associate may provide the notification.

Psychotherapy Notes: We will not disclose your psychotherapy notes without your prior written authorization except for the following:

1. Use by the originator of the notes for your treatment;

2. For training our staff, students, and other trainees;

3. To defend ourselves for legal reasons;

4. If the law requires us to disclose the information to you or the Secretary of HHS or for some other reason;

5. In response to health oversight activities concerning your psychotherapist;

6. To avert a serious and imminent threat to health and safety; or

7. To the coroner or medical examiner after your death.

To the extent you revoke an authorization to use or disclose your psychotherapy notes, we will stop using or disclosing these notes.

Research: We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by our Medical Staff team, in compliance with the governing law.

Fundraising: We may use or disclose your demographic information in order to contact you for our fundraising activities. For example, we may use the dates you received treatment, the department of service, your treating physician, outcome information and health insurance status to identify individuals who may be interested in participating in fundraising activities. If you do not want to receive these materials, notify Western Wisconsin Health Privacy Officer and we will stop any further fundraising communications. Similarly, you should notify Western Wisconsin Health Privacy Officer if you decide you want to start receiving these solicitations again.

When We May NOT Use or Disclose Your Health Information: Except as described in this Notice, this medical practice will not, consistent with its legal obligations, use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

Health Information Exchange (HIE): Wisconsin offers a state-wide, internet-based, electronic health information exchange (HIE) whereby participating healthcare organizations can review your health information as healthcare is provided to you. Your participation is voluntary; however, your health information will be included in this exchange unless you “opt out” as explained below. This electronic HIE could include national information exchange when resources are available.

How is my privacy protected in this electronic health exchange? Participating organizations use a combination of safeguards to protect your health information. Technical safeguards include encryption, password protection, and the ability to track every viewer’s usage of the system. Administrative safeguards include written policies and agreements controlling access to information through a state and/or national HIE. All participating organizations are also regulated by federal and state privacy laws.

Are there privacy risks in this electronic health exchange? Yes. Doctors, hospitals and anyone else who is treating you are already responsible for keeping your health records private. The only added risk is your health record will now be seen through the computer rather than just by mail or fax. The participating organizations believe the potential benefits outweigh the risk, but your participation is a personal decision you must make for yourself.

Can I choose not to participate in this electronic health exchange? Yes. We call this a decision to “opt out”. Your health information will not be available for sharing through this electronic HIE except in cases of an emergency and for public health reporting as permitted by law. Your decision to opt out applies only to electronic sharing your information through the exchange and does not affect other sharing such as secure email, faxing, mail, records maintained by your healthcare provider, etc.

How do I opt out? Contact Western Wisconsin Health Privacy Officer or complete and return the Opt-Out/Revoke Opt-Out Form which is available online at http://wishin.org/ForPatients/PatientChoice.aspx

YOUR HEALTH INFORMATION RIGHTS

Right to Request Special Privacy Protections: You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying information you want to limit, and what limitations on our use or disclosure of information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.

Right to Request Confidential Communications: You have the right to request you receive your health information in a specific way or at a specific location. For example, you may ask we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

Right to Inspect or Copy: You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we cannot agree and we maintain the record in an electronic format, your choice of readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers the costs of labor, supplies, and postage. We may deny your request under limited circumstances. If we deny your request to access your child’s records or records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.

Right to an Accounting of Disclosures: You have the right to receive an accounting of disclosures of your health information made by Western Wisconsin Health, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in under treatment, payment, health care operations, notification and communication with family, and specialized government functions of this brochure (Notice) or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that provides this accounting would be reasonably likely to impede their activities.

Right to Paper or Electronic Copy of this Notice: You have a right to Notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice, even if you have previously requested receipt electronically.

If you would like to have a more detailed explanation of these rights, or if you would like to exercise one or more of these rights, contact Western Wisconsin Health Privacy Officer.

Changes to this Notice of Privacy Practice: We reserve the right to amend this Notice at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. We will also post the current notice on our website.

Complaints: Complaints about this Notice of Privacy Practices or how Western Wisconsin Health handles your health information should be directed to our Privacy Officer. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Office of Civil Rights

US Department of Health and Human Services

233 North Michigan Avenue, Suite 240

Chicago, IL 60601

http://www.hhs.gov/ocr/office

Voice Phone: 312-886-2359 / Fax: 312-886-1807

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

Revision Dates: 07/28/2003 and 09/23/2013

Contact Us Today!

Western Wisconsin Health appreciates your feedback. Let us know how we’re doing so we can provide the best care for all.