This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
PLEASE REVIEW THIS NOTICE CAREFULLY
This notice applies to all patient health information maintained by Community Memorial Hospital for services provided either at the Hospital’s main facility:
Community Memorial Hospital
W180 N8085 Town Hall Road
Menomonee Falls, WI 53051
or at its offsite locations:
Rehabilitation & Sports Medicine Center - Menomonee Falls
N87 W17301 Main Street
Menomonee Falls, WI 53051
Community Recovery Center
N87 W17313 Main Street
Menomonee Falls, WI 53051
Rehabilitation & Sports Medicine Center - Germantown
W175 N11162 Stonewood Drive
Germantown, WI 53022
This Notice describes of the privacy practices of the Hospital and all physicians who are on staff as it relates to providing you care at the Hospital or its offsite locations. If you have any questions after reading this Notice, please contact the Hospital’s 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 at the Hospital and its offsite locations is needed to provide you with quality care and to comply with legal requirements.
The law requires us to:
In certain circumstances we may use and disclose medical information about you without your written authorization:
We will use health information about you to provide you with medical treatment or services. We will disclose health information about you to doctors, nurses, technicians, students in health care training programs, or other CMH personnel who are involved in your care. 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 that you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside the hospital who provide your medical care after you leave the hospital. For example, the physician or nursing home that provides you care following your hospital service will be provided information about your care and treatment.
The Hospital will use and disclose your health information to send bills and collect payment from you, your insurance company, or other payors, such as Medicare.
We will do this for the care, treatment and other related services you receive from the Hospital. We may also provide your name, address and insurance information to other care providers involved in your care at the hospital so they may bill for the services they provided. We may also tell your health insurance company about a treatment your physician has recommended in order to determine whether or not your plan will cover the treatment.
We may use and disclose health information about you for Hospital business operations. These uses and disclosures are necessary to run the Hospital and make sure that all of 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 and students in caring for you. When we use or disclose your healthcare information, it may be to another organization that assists us in operating our hospital. For example, when you doctor dictates a summary of your care an outside company types up the document for our medical records. These outside agencies, who are called "business associates" have signed an agreement with us to keep any healthcare information received from us confidential in the same way we do.
When you are an inpatient, the Hospital may list certain information about you such as your name, your location in the Hospital, and your religious affiliation in a Hospital directory. The Hospital 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 don’t 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.
Marketing and Fundraising Activities
The Hospital may use health information such as your name, address and phone number and the dates you received treatment or services at the Hospital to contact you about new programs as a part of promoting health. The Hospital may disclose this contact information to a foundation associated with the Hospital so that the foundation may contact you for fundraising. If you do not want the Hospital to contact you for fundraising efforts, you must notify the CMH Foundation in writing.
Appointments/Post Discharge Follow-up Calls
The Hospital may contact you to schedule appointments. They may also contact you to see how well you are doing after you are discharged from the hospital. Messages left for you will not contain any health information.
Public Health and Government Functions
The Hospital is required by law to disclose your health information in certain circumstances to:
The hospital is required to release your health information to:
Organ, Eye and Tissue Donation
We are required by law to disclose health information to organ donor organizations that obtain, bank or transplant organs, eyes or tissue.
The hospital may use and share your health information for certain kinds of research. The hospital has a research review board that reviews and approves research projects. The 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 submitted to the review board that include information identifying you with your health information will require your written authorization to use the information before the research begins. If you choose not to participate in a research project your care and treatment will not be affected.
The Hospital may release your health information as it relates to your work injury or illness for workers’ compensation. This program provides you with benefits for work-related injuries or illness.
In all instances where we deal with your protected health information, the Hospital follows a "Minimum Necessary Standard." Every reasonable effort is made to limit the use or, disclosure of, and requests for your health information to the minimum necessary to accomplish the intended purpose or job.
YOUR HEALTH INFORMATION RIGHTS
You have the right to request certain restrictions on the Hospital’s uses or disclosures 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 like a family member or friend.
The Hospital is not required to agree to your request if it interferes with patient care, treatment, hospital operations, and/or payment of your bill.
If the Hospital does agree, it will comply with your request unless the information is needed to provide you emergency treatment. A request for restrictions should be made in writing. To Request a restriction you must complete a request form that is available in Patient Care areas or in Medical Records Department.
You have the right to inspect and receive a copy of your health records. While an inpatient, a request to inspect your records may be made to your nurse or physician. If you are an outpatient, submit your request to the Medical Records Department. For copies of your health information, requests must go to the Medical Record Department. For billing information, contact the Patient Accounts Department.
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 information is maintained by the Hospital. Requests for amending your health information should be made to your nurse if you are in the hospital or to the Medical Records Department after you are discharged from the hospital. The Hospital will respond to your request within 60 days after you submit the written amendment request.
Right to a List of Disclosures
You have the right to request a list of disclosures of your protected health information The list will exclude disclosures authorized by you, those made to carry out treatment, payment and health care operations and those made before April 14, 2003. To request this list of disclosures, you must submit your request in writing to our Medical Records Department. The first list you request 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 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.
Uses and disclosures of health information not covered by this notice or the laws that apply to the Hospital will be made only with your authorization. If you authorize the Hospital to use or disclose your health information, you may revoke that authorization, in writing at anytime. The revocation does not apply to any information that has already been disclosed with your permission. To revoke an authorization you must contact the Medical Record Department.
If you believe your privacy rights have been violated you may file a written complaint with the hospital or with the Secretary of the Department of Health and Human Services. Filing a complaint will not affect your care and treatment.
You may file a written complaint with the hospital by mailing it to our HIPAA Privacy Officer. You may file a written complaint with the Secretary of the Department of Health and Human Services by mailing it to the following address:
Region V, Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
If you want to fax your complaint to the Office for Civil Rights (OCR) fax it to 312.886.1807.
You may, but are not required to, use the OCR’s Health Information Privacy Complaint Form.
To obtain a copy of this form, or for more information about filing a complaint with the OCR, contact any OCR office or go to www.hhs.gov/ocr/hipaa/.
Important: You have the right to obtain a paper copy of this notice, if you received it electronically, by contacting our Medical Records Department. We reserve the right to revise or change this notice. The revised notice will be posted on our web site and displayed in public areas within the hospital and its off-site locations. You may also request a copy of the revised notice.
HIPAA Privacy Officer: 262.257.3409
Medical Records Department: 262.257.3400
Patient Accounts Department: 262.257.3850
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