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Joint Notice of Privacy Practices

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 Froedtert & Community Health affiliates or the Medical College of Wisconsin for services provided. This includes PHI at Froedtert Hospital's main facility, clinics, outpatient areas or other treatment facilities operated by Froedtert Hospital and the Medical College of Wisconsin or by Community Memorial Hospital, its affiliated clinics, outpatient areas or other treatment facilities (all are referred to together in this document as the "F&CH Affiliates"). If you have any questions after reading this Notice, please contact the designated Privacy Officer.

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 HEALTH INFORMATION 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 health information 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 health information 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 health information 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 health information 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 health information 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 health information received from us confidential in the same way we do.
• Family Members and Friends: We may disclose health information 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.
• Appointments: We may contact you for appointment reminders and to communicate necessary information about your appointment.
• Hospital Directory: When you are an inpatient, the F&CH Affiliate hospitals 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.
• Fundraising Activities: We may use health information, 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 designated Privacy Officer to help you with this request.
• Future Communications: We may use your name, address, and phone number to contact you to provide you general health information, 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 health information 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 health information when required to do so by federal, state, or local law. We are permitted, and required in some cases, to release your health information in certain circumstances to:
• Report suspected elder or child abuse to law enforcement 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 or coroner regarding a death.


• Organ, Eye and Tissue Donation: We will disclose health information to organizations that obtain, bank or transplant organs or tissues.
• Research: We may use and share your health information for certain kinds of research. There are research review boards that review and approve research projects. A 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 that identify you with your health information will require your written authorization for their use and disclosure. If you choose not to participate in a research project your care and treatment will not be affected.
• Workers' Compensation: We may provide health information regarding your work-related injury or illness to your workers' compensation carrier. This is so you may receive benefits for work-related injuries or illness.

YOUR HEALTH INFORMATION RIGHTS

Right to Request Restrictions: You have the right to request certain restrictions of our use or disclosure of health information for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your health information to someone who is involved in your care or the payment for your care. We are not required to agree to your request. 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 Patient Care areas or in the Health Information/Medical Records Department.

Right to Inspect and Copy: You have the right to inspect and receive a copy of health information 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 health information, requests must go the Health Information/ Medical Records Department. There may be a charge for these copies. For billing information, you may contact Patient Financial Services.

Right to Amend: If you feel that health information 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 health information 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.

Right to a List of Disclosures: You have the right to request a list of disclosures we have made of your health information. 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. For example, you can ask that we only contact you at work or by mail. We will accommodate all reasonable requests. You must make any such request in writing submitted to the designated Privacy Officer.

Right to Revoke Authorization: If you authorize the F&CH Affiliates to use or disclose your health information, 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. 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 health information 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 262-257-3409
W180 N8085 Town Hall Rd, Menomonee Falls, WI 53051

Health Information/Medical Records Department
Froedtert Hospital 414-805-2909
Medical College of Wisconsin 414-805-5070
Community Memorial Hospital 262-257-3400

Patient Financial Services
Froedtert Hospital 414-805-5951
Medical College of Wisconsin 414-456-4511
Community Memorial Hospital 262-257-3850

Web sites
Froedtert Hospital http://www.froedtert.com
Medical College of Wisconsin http://www.mcw.edu
Community Memorial Hospital http://www.communitymemorial.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 (01/09, supercedes 05/08)