THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
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 & Community 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.
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:
* 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
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.
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)
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