• Other Uses and Disclosures of Your Information Most uses and disclosures of psychotherapy notes require your written authorization. Uses and disclosures of your information for marketing purposes and disclosures that constitute the sale of your information require your written authorization. Other uses and disclosures of your information that are not described above will be made only with your written permission. If you provide the Hospital with an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of your information. However, the revocation will not be effective for information that the Hospital has used or disclosed in reliance on the authorization. YOUR HEALTH INFORMATION RIGHTS • Right to be Notified of a Breach You have the right to be notified in the event that the Hospital (or one of the Hospital’s Business Associates) discovers a breach of your unsecured information. • Right to Request Restrictions You have the right to request certain restrictions of the Hospital’s 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. The Hospital is not required to agree to your request if it interferes with patient care, treatment, hospital/clinic operations and/or payment of your bill. If the Hospital does agree to the restriction, it will comply with your request unless the information is needed to provide you with emergency treatment. The Hospital will agree to restrict disclosure of your information to a health plan if the purpose of the disclosure is for payment or health care operations purposes and your information pertains solely to a service for which you have paid the Hospital in full. A request for restriction must be made in writing. To request a restriction you must complete a request form that is available in patient care areas or in the Medical Records Department. • Right to Inspect and Copy You have the right to inspect and receive a copy of your health records. A request to inspect your records may be made while you are an inpatient to your nurse or physician, or while you are an outpatient, to the Medical Records Department. For copies of your health information, requests must go to the Medical Records Department. For billing information, 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 information is maintained by the Hospital. Requests for amending your health information should be made in writing to the Medical Records Department. The Hospital will respond to your request within 60 days after you submit the written amendment request form. • Right to an Accounting of Disclosures You have a right to request an “accounting of disclosures.” This is a list of those people with whom the Hospital may have shared your health information, with the exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. For example, based on your health information we may have shared your information with the Cancer Registry. To request an accounting of disclosures, you must submit your request in writing to our Medical Records Department. We will provide the list at no cost once during each 12-month period. For any additional requests, we may charge you a fee for the cost of providing the list. We will notify you of the fee and you may choose to withdraw or modify your request at that time before any costs are incurred. • Right to Request Confidential Communications 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 contact you only at work or by mail. We will accommodate all reasonable requests. • Right to Revoke Authorization 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. We are unable to take back any disclosures we have already made with your permission. To revoke an authorization you must contact the Medical Records Department. •R ight to Complain If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the Hospital, contact the Privacy Officer. All complaints must be made in writing. The Privacy Officer will assist you in filing your complaint and the necessary paper work. Filing a complaint will not affect your care and treatment. Important Note: We reserve the right to revise or change this Notice. Each time you sign a consent for treatment at a site covered by this Notice, a copy of the Notice in effect at that time will be available for you. Effective Date: September 23, 2013 How to Contact Us Privacy Officer................................... (414) 266-1773 Medical Records Department........ (414) 266-2100 Patient Financial Services................. (414) 266-6200 Secretary of Department of Health and Human Services............ (877) 696-6775 4836-7793-4869, v. 1 C1943N (9/13) 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. This information is available in Spanish. Please ask a staff member if you need a copy. Esta información esta disponible en español. Si necesita una copia en español, pídala a un miembro del personal. Most patients of Children’s Hospital of Wisconsin are children; when we refer to “you” or “your” in this Notice, we refer to the patient. When we refer to disclosures of information to “you,” we mean disclosures to the patient, the patient’s parent, guardian or other person legally authorized to receive information about the patient. WHO FOLLOWS THIS NOTICE This Notice applies to all patient health information maintained by Children’s Hospital of Wisconsin, its Medical Staff and its affiliates, including Children’s Hospital of Wisconsin hospitals in Milwaukee and Neenah, Surgicenter, specialty care clinics, primary care clinics, urgent care clinics, Community Services locations, as well as Children’s Specialty Group and any other affiliate Children’s Hospital of Wisconsin designates as part of its organized health care arrangement for purposes of HIPAA for services provided at any of its locations. If you have any questions after reading this Notice, please contact the Hospital’s Privacy Officer. Each time you visit the Hospital, your physician or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and billing-related information. This Notice applies to all of the records of your care generated by the Hospital whether made by Hospital employees, agents or your physician. Your physician may have different policies or notices regarding the physician’s use and disclosure of your health information created in the physician’s private office. OUR PLEDGE TO PROTECT YOUR HEALTH INFORMATION We are required by law to maintain the privacy of your health information and provide you with this description of our privacy practices. We will abide by the terms of this Notice. HOW WE MAY USE AND SHARE YOUR HEALTH INFORMATION WITH OTHERS • 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 to Hospital personnel who are involved in taking care of you. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes might slow the healing process. 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, a physician that provides your care following your hospital service will be provided information about your care and treatment here. • Payment 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 Medicaid, for the care, treatment and other related services you receive from the Hospital. We also may provide your name, address, health care and insurance information to other care providers (for example, your physician) who bill for services related to your care at the Hospital. We also may tell your health insurer about a treatment your physician has recommended in order to obtain prior approval or to determine whether your plan will cover the treatment. • Health Care Operations 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, to develop new programs as part of promoting health and to evaluate our performance in caring for you. We also may combine our health information with health information from other hospitals for our staff and students to improve our care and services. In these instances, we remove information that identifies you as an individual from your health information. When we use or disclose your health care information, it may be to another organization that assists us in operating our hospital or clinics. For example, when your physician dictates a summary of his or her visit with you, an outside company types up the document for our medical records. We have contracted with these outside agencies, who are called “business associates,” to keep any health care information received from us confidential. • Hospital Directory When you are an inpatient, the Hospital may list certain information about you such as your name and room number in the patient directory. The Hospital can disclose this information to people who 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 with this request. • F uture Communications and Fundraising Activities The Hospital may use your health information to contact you to provide newsletters, information about wellness programs or other services available to you, or to raise money to support Hospital programs. The Hospital may disclose this contact information to the Children’s Hospital of Wisconsin Foundation so that the Foundation may contact you related to raising money for the Hospital. If you do not want to be contacted for fundraising efforts, you must notify us in writing. Please contact our Privacy Officer to help you with this request. • Required or Permitted By Law The Hospital is required by law to disclose your health information in certain circumstances to: -C ontrol or prevent a communicable disease, injury or disability, to report births and deaths, and for public health oversight activities or interventions. - T he 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. -A state or federal government agency to facilitate their functions. -R eport suspected child abuse to law enforcement agencies responsible to investigate or prosecute abuse. -R espond to a valid court order. - T he Department of Health Services (DHS), a protection or advocacy agency or law enforcement authorities investigating abuse, neglect, physical injury, death, violent crimes involving suspicious wounds, burns, gunshot wounds or death. -Y our court-appointed guardian or an agent appointed by you under a health care power of attorney. -P rison officials if you are in custody. -W orker’s Compensation officials if your injury or illness is work-related. • Organ, Eye and Tissue Donation The Hospital will disclose health information to organizations that obtain, bank or transplant organs, eyes or tissue. • Research Under certain circumstances, the Hospital may use and disclose your health information for research purposes. For example, a research project might compare the health and recovery of all patients who received one medication to those who received another for the same condition. For this type of project, the Hospital Privacy Board may waive the need for consent and any published results would not include information that identifies you. In other circumstances, you will be asked to give consent to participate in a research project. You may choose not to participate in research. Your care and treatment will not be affected by your decision. • Shared Medical Records/Health Information Exchange The Hospital maintains your information in electronic medical records and may allow your health care providers from outside the Hospital to access your information in the Hospital medical records. In accordance with applicable law, the Hospital may participate in electronic health exchanges that facilitate access to your information. When sharing information with others outside the Hospital, we share only what is reasonably necessary unless we are sharing information to help treat you, in response to your written permission, or as the law requires. In these cases, we share all the information that you, your health care provider or the law has requested.