Privacy Statement
NOTICE OF PRIVACY PRACTICES
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.
Your Health-Care Information—Protecting Your Privacy
It is your right as a patient to be informed of the privacy practices of your health-care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.
Black River Memorial Hospital's Responsibilities
It is your right as a patient to be informed of Black River Memorial Hospital's legal duties with respect to protection of the privacy of your personal health information.
Black River Memorial Hospital is required to:
- Maintain the privacy of your health information;
- Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; and
- Abide by the terms of 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 copy of the current notice in the hospital. The notice will contain the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health-care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
Black River Memorial Hospital will not use or disclose your health information without your authorization, except as described in this notice.
Your Health Information Rights
You have the right to:
Request a restriction on certain uses and disclosures of your health information.
You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or Black River Memorial Hospital's payment or health-care operation activities.
We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must complete a Patient Requested Restrictions for Use and Disclosure of Protected Health Information form and return it to Black River Memorial Hospital.
Receive Confidential Communications.
You have the right to request that Black River Memorial Hospital communicate your health information to you by alternative means or at alternative locations. Black River Memorial Hospital shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health-care record.
To request confidential communications, you must complete a Patient Request for Confidential Communication form and return it to Black River Memorial Hospital.
Inspect and obtain a copy of your health record.
You have the right to inspect and obtain a copy of your health-care record. This request for access to your health-care record must be made to the Health Information Department. This right may not apply to certain types of psychotherapy notes. Black River Memorial Hospital may charge you a reasonable fee for a copy of your health-care record.
Request amendment to your health record.
You have the right to request an amendment to your health-care record if you believe your health information is incorrect or incomplete.
To request an amendment, you must complete a Request for Amendment to Protected Health Information form.
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 Black River Memorial Hospital, 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 by or for the hospital;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
Obtain an accounting of disclosures of your health information.
You have the right to an accounting of disclosures of your health information that Black River Memorial Hospital has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure.
To request this list you must complete a Request for Accounting of Disclosure form. 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 list you request within a 12-month period will be free. For additional lists, we may charge you for the cost 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.
Obtain a paper copy of this notice upon request.
You have the right to obtain a paper copy of this notice at any time upon request.
You may obtain a copy of this notice at our web site, www.brmh.net
Uses and Disclosures for Treatment, Payment and Health Care Operations
Black River Memorial Hospital is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment, or health-care operations.
Black River Memorial Hospital may use or disclose your health information for treatment.
Black River Memorial Hospital may use or disclose medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at the hospital. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy, or others we use to provide services that are part of your care.
Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
Example: We may use your health information to provide you with an appointment reminder.
Example: We may send you information about treatment alternatives or other health-related services that may be of interest to you.
Black River Memorial Hospital may use or disclose your health information for payment.
Black River Memorial Hospital may use or disclose medical information about you so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. The bill may include information that identifies you, your diagnosis, and your treatment.
Black River Memorial Hospital may use or disclose your health information for routine health-care operations. Black River Memorial Hospital may use or disclose your health information for evaluation of patient care services, evaluating the performance of health-care providers, activities relating to compliance with the law, and business planning and development. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care.
We may use or disclose medical information about you when we have face-to-face conversations with you about products or services that may be beneficial to you.
We may use medical information about you to contact you in an effort to raise money for the hospital and its operations. We may disclose medical information to a foundation related to the hospital so that the foundation may contact you in raising money for the hospital. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify the Privacy Officer in writing.
We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g. fair, stable, etc.), and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. If you do not want to be listed in the directory or for your information to be given out, you must notify the Privacy Officer in writing.
Example: We may review your health record to determine the efficiency of the services provided to you.
Example: We may disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for peer review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health-care delivery without being able to identify specific patients.
Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization
Without your written authorization, Black River Memorial Hospital may use or disclose your health information for the following purposes:
As Required by Law: We may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:
- Disclosures about victims of elderly or child abuse;
- Disclosures for judicial and administrative proceedings; or
- Disclosures for law enforcement purposes.
Public health: As required by law, we may disclose your protected health information to the State of Wisconsin for the purpose of statutory reporting.
We may disclose your protected health information, excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result, to a state or federal public health agency for the purpose of preventing or controlling disease, injury, or disability.
We may disclose your protected health information, excluding your HIV test result, without your authorization to a county agency investigating child abuse.
We may disclose your protected health information, excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result, without your authorization to the Food and Drug Administration (FDA).
We may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.
We may disclose your protected health information that is reasonably related to a work-related illness or injury if an application for workers' compensation has been filed.
Victims of abuse, neglect, or domestic violence: Black River Memorial Hospital may disclose health information, except for an HIV test result, if we reasonably believe that an individual is a victim of child or elderly abuse.
Health oversight activities: Black River Memorial Hospital will not disclose HIV test results to health-care oversight agencies without an authorization. We may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services, and to a representative of the board on aging and long-term care. The remainder of your protected health information may be disclosed without your authorization to a state or federal agency.
Judicial and Administrative Proceedings: Black River Memorial Hospital may disclose your protected health information, excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result, in response to a court order. We may disclose your protected health information in response to a subpoena if Black River Memorial Hospital is a party to a court action, Black River Memorial Hospital has received your authorization to disclose and has not complied within two business days or we failed to respond to a request for workers' compensation records.
Law enforcement: Black River Memorial Hospital may disclose your protected health information, excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result, if asked to do so by law enforcement officials:
- As required by law;
- In response to a court order, subpoena, warrant, summons, administrative request, or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the hospital;
- In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.
For activities related to death:
Coroner or Medical Examiner: Black River Memorial Hospital may use or disclose your protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse and developmental disabilities to a coroner or medical examiner.
Funeral Director: Black River Memorial Hospital may use or disclose your protected health information, including HIV test results, to funeral directors as necessary to carry out their duties.
Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Research: Black River Memorial Hospital may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.
To avoid a serious threat to health or safety: Black River Memorial Hospital may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.
Disclosures for specialized government functions:
National Security and Intelligence Activities: We may use or disclose protected health information about you to authorized federal officials; for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may use or disclose protected health information about you to authorized federal officials so they may provide protection of the President, other authorized persons, or foreign heads of state to conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Workers’ compensation: Black River Memorial Hospital may disclose protected health information reasonably related to a workers' compensation injury.
Other uses of medical information: Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. If you revoke your permission that was obtained as a condition of obtaining insurance coverage, other law still allows the insurance company to contest a claim under the policy.
Patient Complaint Process
If you believe your privacy rights have been violated, you may file a complaint with Black River Memorial Hospital or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint.
To file a complaint with Black River Memorial Hospital, or if you have questions or concerns regarding your privacy rights or the information in this notice, contact Gina Ransom, the hospital's Privacy Officer at 715-284-5361.
Effective Date: This Notice of Privacy Practice is effective as of April 14, 2003.
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