Notice of Privacy Practices

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.

OUR RESPONSIBILITIES
Columbia St. Mary’s takes the privacy of your health information seriously. We are required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This Notice is provided to tell you about our duties and practices with respect to your information. We are required to abide by the terms of this Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe different ways that we use and disclose your health information. For each category we explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment. We may use health information about you to provide you with treatment, healthcare or other related services. We may disclose your health information to doctors, nurses, aids, technicians or other employees who are involved in taking care of you. Additionally, we may use or disclose your health information to manage or coordinate your treatment, healthcare or other related services. For instance, a doctor treating you for a broken leg would need to know if you have another illness that may slow your healing process. We also may share this information with other people that may help with your medical care after you leave the facility, such as a home health agency or a nursing home.

• For Payment. We may use and disclose your health information to bill and collect for the treatment and services we provide to you. We may send your health information to an insurance company or other third party for the payment purposes including to a collection service. For example, we may need to give your health plan information about surgery you received at the facility so your health plan will pay for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to find out if your plan will cover the treatment.

• For Healthcare Operations. We may use and disclose your health information for healthcare operations. These uses and disclosures are necessary to run Columbia St. Mary’s, to make sure you receive competent, quality healthcare, and to maintain and improve the quality of healthcare we provide. We may also provide your health information to various governmental or accreditation entities to maintain our license and accreditation. For example, we may use medical information to review our treatment and services and to measure how well our staff cared for you. We may also combine information about many facility patients to decide what other types of services the facility should offer or what services are no longer needed. We may share your information for learning purposes. We may also combine information with other facilities to find areas where we can improve the care given.

• As Required By Law. We will disclose your health information when required to do so by federal, state or local law.

• For Public Health Purposes. We may disclose your health information for public health activities. While there may be others, public health activities generally include the following:
• Preventing or controlling disease, injury or disability;
• Reporting births and deaths;
• Reporting defective medical devices or problems with medications;
• Notifying people of recalls of products they may be using; and
• Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

• About Victims of Abuse. We may disclose your health information to notify the appropriate government authority if we believe an individual has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

• Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities might include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government benefit programs, and compliance with civil rights laws.

• Judicial Purposes. We may disclose your health information in response to a court order.

• Law Enforcement. We may release health information if asked to do so by a law enforcement official, if such disclosure is:
• Required by law;
• In response to a court order, warrant, summons or similar process; or
• About criminal conduct at Columbia St. Mary’s.
• Coroners, Medical Examiners and Funeral Directors. In certain circumstances, we may disclose health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
• Organ and Tissue Donation. We may disclose your health 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. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all individuals who received one medication to those who received another. All research projects, however, are subject to a special approval process. This process includes evaluating a proposed research project and its use of health information, trying to balance the research needs with your need for privacy of your health information. Before we use or disclose health information for research, the project will have been approved through this research approval process. Additionally, when it is necessary for research purposes and so long as the health information does not leave Columbia St. Mary’s, we may disclose your health information to researchers preparing to conduct a research project, for example, to help the researchers look for individuals with specific health needs. Lastly, if certain criteria are met, we may disclose your health information to researchers after your death when it is necessary for research purposes.

• To Avert a Serious Threat to Health or Safety. We may use and disclose your health information when we believe it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or lessen the threat or to law enforcement authorities in particular circumstances.

• Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

• National Security and Intelligence Activities. We may release your health information to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities authorized by law.

• Protective Services for the President and Others. We may disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or for the conduct of special investigations.

• Custodial Situations. If you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain representations to us, we may disclose your health information to the medical staff of the facility in which you are confined, the receiving institution’s intake staff to which you may be transferred or a person designated by the facility to maintain prisoner medical records.

• Workers’ Compensation. We may disclose your health information as authorized by and to the extent necessary to comply with workers’ compensation laws or laws relating to similar programs.

• Appointment Reminders. We may use and disclose your health information to provide appointment reminders. If you do not wish us to contact you about appointment reminders, you must notify us.

• Fundraising Activities. We may use your health information to contact you in an effort to raise money for Columbia St. Mary’s and its operations. We may disclose health information to a foundation related to Columbia St. Mary’s so that the foundation may contact you to raise money for Columbia St. Mary’s. In these cases, we would release only contact information, such as your name, address and phone number and the dates you were here. If you do not want us to contact you for fundraising efforts, you must notify the person listed at the bottom of this Notice.

• Facility Directory. We may include certain limited information about you in our directory. This information may include your name, location in the facility, 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 minister, even if they do not ask for you by name. If you do not wish to be included in the facility directory please notify us at the time of admission.

• Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a family member, other relative, or any other person identified by you who is involved in your healthcare. We may also give information to someone who helps pay for your care. We may also tell your family, friends, personal representative or other person responsible for your healthcare your condition and that you are at the facility unless you have objected to us doing so. We may also share information about you to a group or person assisting in a disaster relief effort so that your family can be notified.

• Third Parties. We may disclose your health information to third parties with whom we contract to perform services on our behalf. If we disclose your information to these entities, we will have an agreement by them to safeguard your information.

• Future Communications. We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our facility is participating in.

OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose 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 under the authorization, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding health information we maintain about you:

• Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care.
  
  We are not required to agree to 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 make your request in writing to Medical Records at this facility. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.
• Right to Request Confidential Communications. You have the right to request that we communicate with you or your responsible party about your health care in an alternative way or at a certain location. To request confidential communications, you must make your request in writing to Medical Records at this facility. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to Inspect and Copy. You have the right to inspect and copy health information and/or billing information that may be used to make decisions about your care.
  
  To inspect and copy health information that may be used to make decisions about you, you can submit your request in writing to Medical Records at this facility. To inspect and copy billing information, you can submit your request in writing or orally to Patient Accounting/Business Office at this facility. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

• Right to Amend. You have the right to ask us to amend your health and/or billing information for as long as the information is kept by us.

To request an amendment to your health information, your request must be made in writing and submitted to Medical Records at this facility. To request an amendment to your billing information, your request must be made in writing or orally to Patient Accounting/Business Office at this facility. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it does not include a reason to support the request. For a request for an amendment to your health information, we may deny the request if it is not in writing. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the health information kept by or for us;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

• Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures that we have made of your health information.
  
  To request this list of disclosures, you must submit your request in writing to Medical Records at this facility. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a twelve-month period will be free. For additional lists, during such twelve-month period, 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 a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
  
  To obtain a paper copy of this Notice, contact the Columbia St. Mary’s Privacy Officer at (414) 291-1893.

WHO THIS NOTICE APPLIES TO

This Notice describes Columbia St. Mary’s practices, including the practices of:

• Columbia St. Mary’s Hospital Milwaukee, Inc.
• Sacred Heart Rehabilitation Institute
• Columbia St. Mary’s Hospital Ozaukee, Inc.
• Madison Medical Affiliates, Inc.
• All Columbia St. Mary’s Community Physicians Clinics.

This Notice also covers the practice of:

• Members of Columbia St. Mary’s medical staff and other healthcare providers granted privileges to provide patient care at Columbia St. Mary’s.
• All employees, staff and other Columbia St. Mary’s personnel.
• Healthcare professionals authorized to enter information into or consult your medical record.
• All departments and units of Columbia St. Mary’s, including its clinics.
• Any member of a volunteer group we allow to help you.

All these entities, sites and locations follow the terms of this Notice. In addition, these entities, sites and locations may share health information with each other for treatment, payment or operations purposes described in this Notice.

CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised Notice effective for health 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 a clear and prominent location to which you have access. The Notice is also available to you upon request. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, if we revise the Notice, we will offer you a copy of the current Notice in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Columbia St. Mary’s or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact Columbia St. Mary’s Privacy Officer (414) 291-1893. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

If you have any questions about this Notice, please contact: Columbia St. Mary’s Privacy Officer - (414) 291-1893.