PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes the privacy practices of the Hospital and its medical staff for patients receiving services at the Medical Center.

Reedsburg Area Medical Center must 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 release your health information, we must release 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 release 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. You will be asked to acknowledge receipt of the Notice of Privacy Practices in writing during an admission encounter.

Changes to this notice:

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a current copy of this notice in our facility in the following locations: Main Hospital Lobby Admissions Department, Emergency Room Lobby Admissions Desk, and on the Reedsburg Area Medical Center web site. This notice will contain the effective date. In addition, a copy of this revised notice will be given to you at your request.


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

1. Treatment. 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. We may also share your health information with other healthcare organizations that may participate in your care and treatment such as a hospital to which you may be transferred.

2. Payment. In order for an insurance company to pay for your treatment, we must submit a bill that identifies you, your diagnosis, and the treatment provided to you. As a result, we will pass such health information onto an insurer in order to help receive payment for your medical bills.

3. Health Care Operations. We may need 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. Information Provided to You. In addition, we may want to use your health information for appointment reminders. For example, we may look at your medical record to determine the date and time of your next appointment with us, and then send you a reminder letter to help you remember the appointment.

5. As required or permitted by law. Sometimes we must report some of your health information to legal authorities, such as law enforcement officials, 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. In addition, we may release 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.

6. Workers' Compensation. We may release minimally necessary medical information about you for workers' compensation or similar programs. These programs provide benefits for work related injuries or illness. State and/or federal law control the release of such information.

7. Public Health. As required by law, we may disclose minimally necessary medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report child abuse or neglect by making a telephone report to the Child Abuse Hotline and to follow this report with written confirmation;
• To report reaction to medication or problems with products;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

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

9. For 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.

10. For research. Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research. Such research might try to find out whether a certain treatment is effective in curing an illness.

11. 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 release is necessary to prevent or minimize a serious and approaching threat to you or the public's health or safety.

12. For 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 release your health information to the proper authorities so they may carry out their duties under the law.

Reedsburg Area Medical Center Directory. Unless you object, we may use your health information, such as your name, location in our facility and your religious affiliation for our directory. It is our duty to give you enough information so you can decide whether or not to object to release of this information for our directory. The information about you contained in our directory will be released to people who ask for you by name. However, the information about your religious affiliation will only be disclosed to clergy. If you do not want us to list this information in our directory and provide it to clergy and others, you must tell one of our staff members that you object to this practice.

14. 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 release important health information about you to those people. The information released 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. We may allow you to agree or disagree orally to such release, unless there is an emergency. It is our duty to give you enough information so you can decide whether or not to object to release of your health information to others involved with your care.

NOTE: Except for the situations listed above, including treatment, payment and healthcare operations, we must obtain your specific written authorization for any other release of 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 Health Information Services, 2000 N. Dewey Ave, Reedsburg, WI 53959

Your Health Information Rights: You have several rights with regard to your health information.

Inspect and copy your health information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. However, this right does not apply to psychotherapy notes or information gathered for judicial proceedings, for example. To inspect and copy medical information that may be used to make decisions about you, you must submit your request to the Health Information Services Department. If you request a copy of the information, we may charge a fee for the cost of retrieving, copying, mailing, and any other supplies associated with your request.

Request to amend/correct your health information. If you feel that any of the
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 our facility.

To request an amendment, your request must be made in writing and submitted to the Health Information Department. In addition, you must provide a reason that supports your request.

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 medical information kept at our facility;
Is not of the information which you would be permitted to inspect and copy; or
Is accurate and complete.

3. Request restrictions on certain uses and disclosures. You have the right to 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.

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 all reasonable requests.

Receive a record of disclosures of your health information. In some limited instances, you have the right to ask for a list of the disclosures of your health information we have made during the previous six years, but the request cannot 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 comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year. In addition, we will not include in the list disclosures made to you or for purposes of treatment, payment, health care operations, our directory, national security, law enforcement/corrections, and certain health oversight activities.

To request this accounting of disclosures, you must submit your request in writing, to the Health Information Department. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first accounting you request within a twelve-month period will not include a cost for providing the disclosure list. For additional accountings, 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.

6. 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.

7. Complaint. 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 Reedsburg Area Medical Center Corporate Compliance Officer 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 Corporate Compliance Officer, Reedsburg Area Medical Center, 2000 N. Dewey Ave., Reedsburg, WI 53959, 608/524-6487 ext. 1000, fax 608/524-6566 or email.

This Notice of Medical Information Privacy is Effective April 14, 2003.
REEDSBURG AREA MEDICAL CENTER