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 protected health information (“PHI”) maintained by The Medical College of Wisconsin (“MCW”) and Froedtert Health affiliates: Froedtert Hospital, Community Memorial Hospital of Menomonee Falls, St. Joseph’s Community Hospital of West Bend, West Bend Clinic, West Bend Surgery Center, Kettle Moraine Anesthesiology and Froedtert Surgery Center for services provided at any main facility, clinic, outpatient facility or other location, including employer sponsored services provided at your employment site.  The term “F&CH Affiliates” in this notice includes MCW and all of the F&CH 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 F&CH Affiliates.  The F&CH 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. 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.
• 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, magnetic or recorded in any form that is created or received by the F&CH Affiliate as a health care provider. PHI is individually identifiable under HIPAA if it includes the name, address, zip code, geographical codes, date of birth, other elements of dates, telephone or fax numbers, email address, social security number, insurance information, medical record number, member or account number, certificate/license numbers, voice or finger prints, photos or any other unique identifying numbers, characteristics or codes of you, your relatives, employers, or household members. 

When releasing your PHI, the F&CH 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 F&CH 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 F&CH 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 F&CH 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 judgement to determine whether disclosing limited PHI is in your best interest under the circumstances. 
• Appointments: We may use and disclose PHI to contact you for appointment reminders and to communicate necessary information about your appointment.
• Hospital Directory: When you are an inpatient admitted to the hospital, or are admitted as an outpatient to the surgery center, the F&CH 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 and the dates you received services, to contact you to raise money for the F&CH Affiliate. We may share this information with a foundation associated with the F&CH Affiliate to work on its behalf. If you do not want the F&CH Affiliates to contact you for our fundraising, you must notify us in writing. Please contact the Privacy Officer or designee to help you with this request.
• Future Communications: We may use your name, address, and phone number to contact you to provide you general PHI, information about new programs or other services we offer, or the F&CH 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: An F&CH Affiliate and College may use and share your health information for certain kinds of research.  The F&CH Affiliate 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 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 F&CH 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 F&CH Affiliate 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 the Health Information/Medical Records Department.  For this request to be approved and valid, it must be signed by the Privacy Officer or designee.

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 F&CH Affiliate maintains the information. Requests for amending your PHI should be made to the Health Information Management/Medical Records Department. The F&CH 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 Management/Medical Records Department. The first list you request from each F&CH 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 health information 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 Revoke Authorization: If you authorize the F&CH 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 Management/Medical Record Department.

Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with the relevant F&CH Affiliate or with the Secretary of the Department of Health and Human Services.  To file a complaint with an F&CH 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 F&CH 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 Hospital 414-805-2895
9200 W. Wisconsin Avenue, Wauwatosa,WI 53226

Medical College of Wisconsin 1-866-857-4943
8701 Watertown Plank Rd, Wauwatosa, WI 53226

Community Memorial Hospital 414-805-2895
W180 N8085 Town Hall Rd, Menomonee Falls, WI 53051

St. Joseph’s Hospital 414-805-2895
3200 Pleasant Valley Road, West Bend, WI 53095

West Bend Clinic  414-805-2895
1700 W. Paradise Drive, West Bend, WI  53095

Health Information/Medical Records Department
Froedtert Hospital 414-805-2909
Medical College of Wisconsin 414-805-5070
Community Memorial Hospital 262-257-3400
St. Joseph’s Hospital  262-836-5057
West Bend Clinic 800-825-0513 ext. 2118

Patient Financial Services
Froedtert Hospital 414-805-5951
Medical College of Wisconsin 414-456-4511
Community Memorial Hospital 262-257-3850
St. Joseph’s Hospital  262-334-8210
West Bend Clinic  262-306-6278 or 800-724-1673

Web sites
Froedtert Hospital http://www.froedtert.com
Medical College of Wisconsin http://www.mcw.edu
Community Memorial Hospital http://www.communitymemorial.com
St. Joseph's Hospital http://www.stjosephswb.com
West Bend Clinic http://www.westbendclinic.com


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 312-886-2359
FAX 312-886-1807
TTD 312-353-5693
E-mail: ocrcomplaint@hhs.gov

Effective Date: April 14th, 2003
Item #: 37974 (04/10, supercedes 07/09)