Notice Of Privacy Practices

• ThedaCare, Inc. and its affiliate hospitals, Appleton Medical Center, Inc. and Theda Clark Medical Center, Inc.
• All locations where ThedaCare provides health care services. These locations include:
  
  
  • All ThedaCare physician clinics;
  • Peabody Manor Nursing Home;
  • Cherry Meadow (hospice facility);
  • The Heritage (which includes the community-based residential facility);
  • ThedaCare at Home (home health agency); and
  • Other ThedaCare-sponsored programs and services.
    
    
• Other health care providers affiliated with ThedaCare, as designated in writing in an Affiliated Covered Entity Agreement. For a list of health care providers currently affiliated with ThedaCare, please contact the ThedaCare Privacy Officer as described below.

For ease of reference, each of the entities listed above shall be referred to in this Notice as “ThedaCare.”

You may receive this Notice at any of our ThedaCare locations. It will serve as notice for all locations and entities noted above.

ThedaCare must by law, maintain the privacy of your personal health information and give you this notice that describes our legal duties and privacy practices concerning your personal health information. In general, when we use or disclose your health information, we must use or disclose only the information we need to achieve the purpose of the use or disclosure. However, all of your personal health information that you designate will be available for disclosure if you sign an authorization form, if you request the information for yourself, to a provider regarding your treatment, or due to a legal requirement. We must follow the privacy practices described in this notice.

However, we reserve the right to change the privacy practices described in this notice, in accordance with the law. Changes to our privacy practices would apply to all health information we maintain. If we change our privacy practices, the revised notice will be posted at the ThedaCare facilities and on our website and we will provide you with a copy at your request.

If you have any questions about any part of this Notice, or if you want more information about the privacy practices at ThedaCare, please contact HIPAA Privacy Official at 920-969-7440.

A.               Uses and Disclosures of Special Health Information

Federal and State law create separate privacy protections for certain information that we will call “Special Health Information.” Special Health Information is information that:

1. relates to treatment of mental illness or developmental disability, including the identity of persons receiving such treatment;
2. relates to the identity, diagnosis, prognosis, or treatment for alcohol or drug dependency;
3. is maintained in psychotherapy notes;
4. relates to HIV test results; or
5. relates to child abuse or neglect.

In order for us to use or disclose Special Health Information for a purpose other than allowed or required by law, we must obtain your written authorization. Except for treatment purposes described in Section B below, we will generally obtain your written authorization for use or disclosure of Special Health Information for the purposes described in Section B. You should be aware that Wisconsin law allows for disclosure of Special Health Information for certain purposes without your written authorization. For example, we may disclose information about treatment of mental illness or developmental disability for certain program monitoring and evaluation purposes, or to legal counsel or to a guardian ad litem to prepare for involuntary commitment proceedings.

B.               How ThedaCare May Use or Disclose Your Health Information

Without your written authorization, we may use your health information for the following purposes:

1.                  Treatment. We may use or disclose your health information to provide treatment to you. For example, a doctor may use the information in your medical record to determine which treatment option, such as a drug or surgery, best addresses your health needs. The treatment selected will be documented in your medical record, so that other health care professionals can make informed decisions about your care. Your medical record may be a combination of a paper medical record and an electronic medical record.

2.                  Payment. We may use and disclose health information about you so that the treatment and services you receive at the hospital may be billed to (and payment may be collected from) you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

3.                  Health care operations.We may use or disclose your health care information for our health care operations, including, but not limited to, evaluating patient care and business planning. For example, we may use your diagnosis, treatment, and outcome information in order to improve the quality or cost of care we deliver. These quality and cost improvement activities may include evaluating the performance of your doctors, nurses and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to patients in similar situations.

4.                  Appointment reminders. We may use your health information for appointment reminders. For example, we may look at your health information to determine the date and time of your next appointment with us, and then send you a written or phone call reminder to help you remember the appointment.

5.                  Treatment alternatives. We may use your health information and decide that another treatment or a new service we offer may interest you. For example, we may contact cancer patients to notify them that we have a new cancer research facility that offers new life-saving treatments.

6.                  Fundraising. We may use your health information to contact you for a ThedaCare entity’s fundraising purposes. For example, in order to provide more charity care or otherwise improve the health of your community, we may want to raise additional money and therefore may contact you for a donation.

You also have the right to opt out of receiving fundraising communications. You may do so by contacting our Privacy Officer at the address provided in Section B, below.

7.                  As required by law. Sometimes we must report some of your health information to legal authorities, such as law enforcement officials in response to a court order, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order. We may also disclose your health information in the course of an administrative or judicial proceeding in response to a court order.

8.                  Public health activities. We may disclose your health information to authorities to help prevent or control disease, injury, or disability. This may include using your health information to report certain diseases, injuries, birth or death information, information of concern to the Food and Drug Administration, or information related to child abuse or neglect. We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety.

9.                  Health oversight activities. We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs. Some examples include The Joint Commission and state surveyors.

10.              Activities related to death. We may disclose health information to coroners, medical examiners and funeral directors so they can carry out their duties related to death, such as identifying the body, determining cause of death, or in the case of funeral directors, to carry out funeral preparation activities.

11.              Organ, eye or tissue donation. We may disclose your health information to people involved with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.

12.              Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients' need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process. We may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the health information they review does not leave the hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.

13.              To avoid a serious threat to health or safety. As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such disclosure is necessary to prevent or minimize a serious and approaching threat to your, a particular person’s or the public’s health or safety.

14.              Military, national security, or incarceration/law enforcement custody. If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may disclose your health information to the proper authorities so they may carry out their duties under the law.

15.              Workers’ compensation. 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.

16.              Hospital or long-term care locations directory. Unless you object, we may use your health information, such as your name, location in our facility, your general health condition (e.g., “stable,” or “unstable”), and your religious affiliation for our directory. We will give you enough information so you can decide whether to object to use of this information for our directory. If you do not object, the information about you contained in our directory will be disclosed to people who ask for you by name. However, the information about your religious affiliation will be disclosed only to clergy.

17.              To those involved with your care or payment of your care. If people such as family members, relatives, or close personal friends are helping care for you or helping you pay your medical bills, we may disclose important health information about you to those people. The information disclosed to these people may include your location within our facility, your general condition, or death. You have the right to object to such disclosure, unless you are unable to function or there is an emergency. 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 status. We will give you enough information so you can decide whether to object to release of your health information to others involved with your care.

18.              Shared Medical record/Health information Exchange. We participate in arrangements of health care organization, which have agreed to work with each other, to facilitate access to health information that may be relevant to your care. For example, if you are admitted to a hospital on an emergency basis and cannot provide important information about your health condition, these arrangements will allow us to make your health information from other participants available to those who need it to treat you at the hospital. When it is needed, ready access to your health information means better care for you. We store health information about our patients in a joint electronic medical record with other health care providers who participate in the arrangement. Each participant in the shared electronic medical record has implemented policies and procedures governing appropriate access to health information in the shared electronic medical record in accordance with state and federal law.

SPECIAL NOTE: Except for the situations listed above, we must obtain your specific written authorization for any other release of your health information. For example, wemust obtain your written authorization for most sharing of psychotherapy notes, to use and disclose your health information for marketing purposes, or to sell your health information.If you sign an authorization form, you may withdraw your authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to the:

C.               Your Health Information Rights

You have several rights with regard to your health information. If you wish to exercise any of the following rights, please contact:

D.              

Specifically, you have the right to:

1.         Inspect and copy your health information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. You have the right to request that the copy be provided in an electronic form or format (e.g., PDF saved onto CD). If the form and format are not readily producible, then the organization will work with you to create a reasonable electronic form or format. However, this right does not apply to “psychotherapy notes” (information relating to mental health maintained separately from the medical record) or information gathered for judicial proceedings, for example. In addition, we may charge you a reasonable fee if you want a copy of your health information.

2.         Request to correct your health information. If you believe your health information is incorrect, you may ask us to correct the information. You may be asked to make such requests in writing and to give a reason why your health information should be changed. However, if we did not create the health information that you believe is incorrect, or if we disagree with you and believe your health information is correct, we may deny your request.

3.         Request restrictions on certain uses and disclosures. You have the right 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. Or, you may want to limit the health information provided to family or friends involved in your care or payment of medical bills. You may also want to limit the health information provided to authorities involved with disaster relief efforts. However, we are not required to agree in all circumstances to your requested restriction. We must agree to your request for a restriction on the disclosure of your health information to a health plan for payment or health care operations if the health information pertains solely to items and services paid in full by you or another person (other than the health plan) on your behalf, unless the disclosure is required by law.

If you receive certain medical devices (for example, life-supporting devices used outside our facility), you may refuse to release your name, address, telephone number, social security number or other identifying information for purpose of tracking the medical device.

4.         As applicable, receive confidential communication of health information. You have the right to ask that we communicate your health information to you in different ways or places. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address. We must accommodate reasonable requests.

5.        Receive a list of disclosures of your health information. You have the right to ask for a list of certain disclosures of your health information we have made during the previous six years, but the request may not include dates before April 14, 2003. This list must 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 must generally comply with your request for a list within 60 days, although we may have a 30-day extension if we are unable to provide the accounting within 60 days and we provide you with written notice of the reasons for the delay, along with the date by which we will provide the accounting. We may not charge you for the list, unless you request such list more than once per year (in which case we may charge you a reasonable fee). This list will not include disclosures made to you, authorized by you, for purposes of treatment, payment, health care operations, our directory, national security, law enforcement/corrections, certain health oversight activities, and certain other purposes.

6.         Obtain a paper copy of this notice. Upon your request, you may at any time receive a paper copy of this notice, even if you earlier agreed to receive this notice electronically. The website is www.thedacare.org.

8.        To receive notification about breaches of unsecured health information.   You have a right to and will receive notification regarding any breaches of your unsecured health information.

9.        Complain. If you believe your privacy rights have been violated, you may file a complaint with us and with the federal Department of Health and Human Services. We will not retaliate against you for filing such a complaint. To file a complaint with either entity, please contact the Privacy Officer (see contact information below) who will provide you with the necessary assistance and paperwork.

Again, if you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:

This Notice of Privacy Practices is Effective July 1, 2014.
11492017.2

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