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THIS NOTICE DESCRIBES:

(1) HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED: AND

(2) HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

CONTACT INFORMATION: If you have any questions about this notice, please contact the Director of Health Information Management at 608-489-8130 and/or P.O. Box 527, Hillsboro, WI 54634.

Any health care professional authorized to enter information obtained in the hospital setting, nursing home, or St. Joseph’s Clinics into your medical record at “St. Joseph’s” (as defined below).

Any member of a volunteer group we allow to assist with your care while you are receiving services from St. Joseph’s.

All employees, staff and members of the workforce of St. Joseph's Community Health Services, including hospital, nursing home and any St. Joseph Clinic. All of these entities and locations will follow the terms of this notice and are included when the term “St. Joseph’s” is used. In addition, these entities and locations may share medical information with each other for treatment, payment or health care operations purposes and with others performing these activities for us or on our behalf.

This notice applies to all of the records of your care generated by or through St. Joseph’s, whether made by members of our workforce or your personal doctor. Your personal doctor may have a separate notice describing his or her policies regarding use of your medical information that was created in the doctor’s office or clinic. If your personal doctor is employed by St. Joseph’s he or she will follow the practices described in this notice.

OUR DUTIES REGARDING YOUR MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.

· Give you this notice of our legal duties and privacy practices with respect to medical information about you; and

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Ø For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other members of St. Joseph’s workforce who are involved in taking care of you through St. Joseph’s. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian you have diabetes so that we can arrange for appropriate meals. Different departments of St. Joseph’s may also share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside St. Joseph’s who may be involved in your medical care after you leave St. Joseph’s, such as home health nurses or others who provide services that are part of your care. [45 C.F.R. 164.520(b)(1)(ii)(A); 164.502(a)(1)(ii); 164.502(a)(1)(iii)]

Ø For Payment. We may use and disclose medical information about you so that the treatment and services you receive at St. Joseph’s 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 St. Joseph’s 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. [45 C.F.R. 164.520(b)(1)(A); 164.502(a)(1)(ii); 164.502(a)(1)(iii)]

Ø For Health Care Operations. We may use and disclose medical information about you for health care operations purposes. These uses and disclosures are necessary to run St. Joseph’s and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many St. Joseph’s patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other members of St. Joseph’s workforce for review and learning purposes. We may also combine the medical information we have with medical information from other providers to compare how we are doing and see where we can make improvements in the care and services we offer. In using your information for purposes of evaluation and improvement of our services, we may remove information that identifies you from this set of medical information so it can be used to study health care and health care delivery without learning who the specific patients are. We may also disclose information to others we hire to assist with our health care operations, such as accountants or consultants. [45 C.F.R. 164.520(b)(1)(II)(A); 164.502 (a)(1)(ii); 164.502(a)(1)(iii)]

Ø Personal Contact. We may use and disclose medical information to establish personal contact for the following reasons

Ø Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Ø Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Ø Fundraising Activities. We may use information about you to contact you in an effort to raise money for St. Joseph’s and its operations. We may disclose information to a foundation related to St. Joseph’s so that the foundation may contact you to raise money for St. Joseph’s. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services from St. Joseph’s. If you do not want us to contact you for fundraising efforts, you must notify St. Joseph’s Community’s Outreach Director in writing.

Ø Directory. We may include certain limited information about you in our facility directory while you are a patient at St. Joseph’s. This information may include your name, location within our facility, your general condition (e.g. fair, stable, etc.) and your religious affiliations. The directory information, except for your religious affiliation, may also be released to people who ask for you by name unless otherwise prohibited by law. This is so your family, friends and clergy can visit you and generally know how you are doing. Your religious affiliations may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. If you do not want to be listed in the directory or have your information be given out, you must notify the Director of Health Information Management in writing.

Ø Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends about your condition and that you are at St. Joseph’s. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you do not want St. Joseph’s to disclose information about you in these situations, you must notify our Director of Health Information Management in writing.

Ø Research. Under certain circumstances, we may use and disclose medical 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 medical information, trying to balance the research needs with patients’ need for privacy of their medical information.

Ø As Required By Law. We will disclose medical information about you when required to do so by federal or state law.

Ø To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or lessen the threat, including the target of the threat.

Ø Organ and Tissue Donation. If you are an organ donor, we may release medial information to organizations that handle organ procurement or organ eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.

Ø Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities when authorized by law.

Ø Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Ø Public Health Activities. We may disclose medical information about you for public health activities. These activities generally include the following:

· To notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition;

· To report specified health care data to the Office of Health Care Information;

· To notify the appropriate government authority if we believe a patient has been the victim of caregiver abuse, neglect or misappropriation of property; and

· To an employer to facilitate workplace medical surveillance as required by law.

Ø Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure and disciplinary actions. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Ø Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a valid court order or federal grand jury subpoena. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if we have obtained your permission or were unsuccessful in our efforts to obtain an order protecting the information requested.

Ø Law Enforcement. We may release medical information to law enforcement officials:

Ø Coroners and Medical Examiners. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Ø National Security and Intelligence Activities. We may release medical information about you to authorized federal officials; for intelligence, counterintelligence, and other national security activities authorized by law.

Ø Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protections to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Ø Inmates. If you are an inmate or in the custody of a correctional institution, we may release medical information about you to the medical staff or intake staff of the correctional institution or the Department of Corrections when authorized by law.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.

You have the following rights regarding medical information we maintain about you:

Ø Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to all requests. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment to you.

To request restrictions, you must make your request in writing to the Director of Health Information Management. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Ø Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Director of Health information Management. We will not ask you the reason for your request. We will accommodate all reasonable requests.

Ø Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include information compiled in anticipation of a legal proceeding or psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Director of Health Information Management. If you request a copy of the information, we may charge a fee for the costs of copying, matting or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. A licensed health care professional chosen by St. Joseph’s will review your request and the denial. The person conducting the review will not be the person who denied your request.

Ø Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for St. Joseph’s.

To request an amendment, your request must be made in writing on our Request for Amendment form and include your reason for requesting the amendment. Your request should be submitted to the Director of Health Information Management.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

· Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

· Is not part of the information which you would be permitted to inspect and copy; or

You may appeal a decision by us not to amend a record by completing the appropriate form and submitting it to our Director of Health Information Management.

Ø Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is an accounting of the disclosures we made of medical information about you, other than certain disclosures that are not required to be included in the accounting, such as disclosures made for the purposes of treatment, payment or health care operations or pursuant to your authorization.

To request this accounting of disclosures, you must submit your request in writing to the Director of Health information Management. Your request must: (1) be made on the appropriate form; (2) specify the facility for which the accounting is to be provided; (3) be directed to the facility where the record was created; and (4) state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the accounting (for example, on paper or electronically). The first accounting you request within a 12-month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. 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.

Ø Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact the Director of Health Information Management.

We reserve the right to change this notice. We reserve the right to make the revised notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at St. Joseph’s. The notice will contain on the first page, in the top right-hand corner, the effective date.

If you believe your privacy rights have been violated, you may file a complaint with St. Joseph’s or with the Department of Health and Human Services. To file a complaint with St. Joseph’s, contact the Office of the CEO, St. Joseph’s Community Health Services, P.O. Box 527, Hillsboro, WI 54634; 608-489-8100. Complaints to the Department of Health and Human Services should be sent to the Secretary of the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, DC 20201. All complaints must be submitted in writing.

For specific regulations regarding the privacy rules and components of this notice, see 45 C.F.R., Section 164.5

I acknowledge that I have received and reviewed the “Notice of Privacy Practices.” I know that I may request a copy of the “Notice of Privacy Practices” at any time. I am aware that this acknowledgement remains in effect and as a permanent part of the medical record for as long as the record is maintained at St. Joseph's.

FOR USE BY ST. JOSEPH’S COMMUNITY HEALTH SERVICES

I attempted to obtain the patient’s/resident’s signature acknowledging his/her receipt of the Notice of Privacy Practices, but was unable to do so as documented below:

Date:

Patient/Resident Name:

Employee Name:

Reason patient/resident did not sign: ______________________________________________________________________

OUR DUTIES REGARDING YOUR MEDICAL INFORMATION

For more information, please contact:

St. Joseph's Community Health Services
400 Water Avenue
P.O. Box 527
Hillsboro, Wisconsin 54634

OUR DUTIES REGARDING YOUR MEDICAL INFORMATION

For more information, please contact:

St. Joseph's Community Health Services 400 Water Avenue P.O. Box 527 Hillsboro, Wisconsin 54634

St. Joseph's Community Health Services
400 Water Avenue
P.O. Box 527
Hillsboro, Wisconsin 54634