Rogers Memorial Notice of Privacy Practices - Wisconsin

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.

Rogers Memorial Hospital, Inc. d/b/s Rogers Behavioral Health ("Rogers") is required by law to maintain the privacy of your health information and to provide you with a notice that describes Rogers' legal duties and privacy practices concerning your health information. Health information is information that we have created and/or received about you that may identify you (such as your name, address, phone number), as well as your symptoms, examinations, test results, diagnosis, treatment and plans for future care or treatment. We will follow the privacy practices described in this notice. If you have any questions about any part of this notice or if you want more information about the privacy practices of Rogers, please contact the Privacy Officer at 34700 Valley Road, Oconomowoc, WI 53066 (262) 646-1397.

We reserve the right to change the privacy practices described in this notice. We reserve the right to apply any changes to this notice to the health information that is already in our possession as well as any future information. You may review our notice at any time on our website at https://rogersbh.org. You may also obtain a current copy of our notice at each of our health care locations, or by contacting our Privacy Officer.

WHO WILL FOLLOW THIS NOTICE?

Rogers participates in an organized health care arrangement for compliance with the Health Insurance Portability and Accountability Act ("HIPAA"). Rogers is a clinically integrated care setting in which patients receive care from Rogers staff and from independent health care providers who participate in your care ("Integrated Care Team"). As part of this arrangement, we share your health information with each other as necessary for your treatment, to get paid for our services, and to carry out other health care operational activities of the Integrated Care Team. This Joint Notice of Privacy Practices ("Notice") provided to you by any one of the Integrated Care Team participants will also satisfy the HIPAA requirement for providing notice for all others covered by this Notice. This Notice applies to services provided by Rogers clinics, facilities, programs and affiliated clinical practices at the care delivery sites listed at the end of this Notice. This Notice will be followed by:

• All employees of Rogers

• All members of the medical staff and other health care providers who provide treatment to you while you are a patient of Rogers

• Any student, volunteer or other person authorized to assist with your care while you are a patient of Rogers

The Notice does not cover the privacy practices of independent health care providers at other settings and locations not covered by this Notice or part of the Integrated Care Team.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Wisconsin laws restrict the use or disclosure of your health information relating to treatment for mental health, development disabilities, alcoholism, drug dependence or information concerning HIV status, without obtaining your authorization. Certain federal laws may also restrict the use or disclosure of such information. If your health information involve such information, the information will be handled, used and disclosed only as permitted by law or with your authorization. In several instances, Federal SUD Regulations in 42 CFR Part 2 are more restrictive and we will comply with the more restrictive laws as applicable.

The following categories describe different ways we may use and disclose health information about you without your authorization. For each category of uses or disclosures we will give examples to help you understand what we mean. Not every use or disclosure in a category will be listed. We will make reasonable efforts to use, disclose only the minimum amount of health information needed to accomplish the intended purpose of the task.

Treatment. We may use or disclose your health information to other health providers for your continuity of care. We may disclose your health information to physicians, psychologists, nurses or other health care personnel who provide you with health care services or who are involved in your care. For example, a physician may review your health information to determine if a medication is appropriate for your care.

Payment. We may use or disclose health information about you so that the treatment services you receive may be billed to, and payment may be collected from you, an insurance company or another third-party payer. For example, we may provide portions of your health information such as your name, diagnosis and the specific treatment that you are receiving to our billing department and your health plan to get paid for services provided to you. In certain situations, we may disclose your health information to a collection agency if a bill is not paid.

Health Care Operations. We may use your health care information as necessary for our individual and permitted joint health care operations which may include quality assurance and improvement activities, evaluation of the performance of health care providers, legal services, risk management business planning and compliance with law. For example, we may use your information to look at the care you received from doctors, nurses, or other health care providers. We may use your health information for our accreditation activities.

Fundraising. We may use or disclose to the Rogers Memorial Hospital Foundation certain limited information from your record (excluding any alcohol and other drug abuse records) for fundraising purposes in accordance with applicable privacy laws, which information shall be limited to the following: limited demographic information, including your name, address, and/or other contact information (or that of your personal representative, as applicable); dates of health care provided to you, and names of your treating physician(s). The Foundation has no access to your health information and, if applicable, will be provided only the limited information noted above from Rogers for fundraising purposes. In each fundraising communication received, either from Rogers directly or from the Foundation, you will be provided the opportunity to opt-out of receiving further fundraising communications in the future.

Additional ways we may use or disclose your health information without your written authorization, as permitted or required by law:

Family and Care Givers for Care. We may disclose limited health information about you to your spouse, domestic partner, parent, adult child or sibling if such individuals are directly involved in your care or monitoring your treatment as verified by your physician, psychologist or by a person other than the individual requesting the information. The health information released would not include alcohol and drug abuse services and would be limited to, a summary of your diagnosis and prognosis, a listing of medications received or you are receiving, and a description of your treatment plan. If you are able and available to agree or object, we will give you the opportunity to agree or object to such uses and disclosures. If you are not available or in the event of your incapacity or emergency circumstances, we will disclose health information using professional judgment disclosing only information that is directly relevant to person's involvement in your health care.

Required by Law. We may use and disclose your health information when that use or disclosure is required by local, state or federal law. For example, we are required to report actual and suspected abuse, neglect or violence relating to children and the elderly. We are also required to respond to a court order.

Public Health. We may disclose your health information to local, state or federal public health agencies, subject to the provisions of applicable law, to help prevent or control disease, injury, or disability. For example, we are required to report certain diseases, injuries, and problems with products and reactions to medications to the Food and Drug Administration.

Health Oversight Activities. We may disclose your health information to authorities and agencies designated by the government or as required by law, for purposes such as management audits, financial audits or program monitoring and evaluation.

Judicial and Administrative Proceedings. We may disclose your health information in the course of an administrative or judicial proceeding for such purposes as response to a court order or associated with a petition filed in court related to treatment.

Law Enforcement. We may disclose your health information to a law enforcement official as required or permitted by law. For example, we may disclose health information to report an apparent crime committed on the premises, assist with identifying and locating a missing patient, or comply with a court order.

Coroners and Medical Examiners. We may disclose your health information to coroners, medical examiners, law enforcement, and other authorities as required or permitted by law so they can carry out their duties related to your death, such as determining cause of death.

Research. Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research. The researchers agree not to disclose information that would allow you to be identified, except as allowed by law. For example, the research study may measure the success of a treatment or medication in treating an illness or condition.

Avert Serious Threats to Health or Safety. We may disclose your health information in a very limited manner to appropriate persons to prevent a serious threat to the health and safety of a particular person or general public. Disclosure is usually limited to law enforcement personnel who are involved in protecting the public safety or others in a position to prevent the threat.

For Workers’ Compensation. We may disclose your health information to the appropriate persons in order to comply with the laws related to Workers’ Compensation or other similar programs. These programs may provide benefits for work-related injuries or illness.

Health Information. We may use or disclose your health information to provide information to you or about treatment alternatives or other health-related benefits and services that may be of interest to you.

Facility Directory. We may use your health information, such as your name, location in our facility, and your religious affiliation for our directory. Unless there is a specific written request from you to the contrary, we can disclose this directory information, except for your religious affiliation, to people who ask for you by name. Your religious affiliation may be given to the members of the clergy even if they do not ask for you by name.

Correctional Facility, Probation or Parole. If you are an inmate of a correctional facility or under supervision for probation or parole, we may disclose your health information to the correctional facility, the Department of Corrections, probation and parole agents and other authorized authorities for your health and the health and safety of others.

 

WHEN WE ARE REQUIRED TO OBTAIN AN AUTHORIZATION TO USE OR DISCLOSE YOUR HEALTH INFORMATION

Except as described in this Notice, we will not use or disclose your health information without your written authorization. For example, your authorization is required for most uses and disclosures of health information for marketing purposes and the sale of health information.

Your authorization is required for most uses and disclosures of psychotherapy notes which are notes recorded by a mental health provider documenting or analyzing the contents of conversation with you during counseling sessions that are kept separate from the rest of your health information . If you authorize us to use or disclose your health information, you may revoke that authorization, in writing, at any time to stop any future uses and disclosures (to the extent that we have not taken any action relying on the authorization).

If you wish to withdraw your authorization, please contact the Health Information Department, Release of Information, 1-800-767-4411 select option “3”.

WHAT RIGHTS YOU HAVE REGARDING YOUR HEALTH INFORMATION

You have several rights with regard to your health information. Specifically, you have the right to:

Inspect and Copy your Health Information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. If you request copies of your health information, we may charge for the costs of providing the copies. If you request an electronic copy and the health information you are requesting is maintained electronically, we would provide the copy electronically in the form you request if it is readily producible, or if not,

in an agreed upon readable electronic form. You have the right to request, in writing, that we transmit a copy of your health information directly to another individual. This right to access does not apply to psychotherapy notes, which are maintained for personal use of a mental health professional.

Your request to inspect or access your health information must be in writing to:

Rogers Memorial Hospital, Health Information Department, Release of Information 34700 Valley Road, Oconomowoc, WI 53066 or contact 1-800-767-4411 select option “3”

Request to Amend Your Health Information. You have a right to request that we amend your health information that you believe is incorrect or incomplete. We are not required to change your health information and may deny your request in writing if the health information is correct and complete, not created by us, or not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and our denial be attached to all future disclosures of your health information. If we approve your request to amend, we will make the changes to your health information and make reasonable efforts to inform others about the change to your health information. To request an amendment, you must make your request in writing to the Health Information Manager 34700 Valley Road, Oconomowoc, WI 53066. You must also provide a reason for your request. Changes to non-clinical information such as changes of address and insurance information are not amendments and may be routinely processed.

Request Restrictions on Certain Uses and Disclosures. You have the right to request restrictions on the use and disclosure of your health information for treatment, payment or health care operation activities. Additionally, you have the right to request restrictions on disclosure of information to individuals involved in your care. We are not required to agree to your requested restrictions in most cases. If we do agree, we will comply with your restriction unless the information is needed to provide you emergency treatment or until the agreement is terminated. We must, however, agree to your request to restrict disclosure of your health information, to a health plan for the purpose of carrying out payment or health care operations, if it is not otherwise required by law, and, the health information pertains solely to a health care item or service for which you, or a third party other than the health plan, have paid us for in full. If you would like to make a request for restrictions, you must submit your request in writing to the Health Information Manager, Rogers Memorial Hospital, 34700 Valley Road, Oconomowoc, WI 53066. We will inform you if we cannot carry out your request.

Receive Confidential Communication of Health Information. You have the right to request that we communicate your health information to you in a certain way or at a certain location. For example, you may ask that we only contact you at work or by U.S. Mail. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

To request confidential communications, you must submit your request in writing to the Health Information Manager 34700 Valley Road, Oconomowoc, WI 53066.

Receive a Record of Disclosures of Your Health Information. You have the right to request, in writing, a record of certain types of disclosures we made of your health information to individuals or organizations for the six years prior to the date on which the accounting is requested, or a shorter period of time if requested. We are not required to provide a record of the following disclosures:

• To carry out treatment, payment, and health care operations;

• To individuals regarding information about themselves;

• Incident to a use or disclosure otherwise permitted by applicable law;

• To persons involved in the individual’s care, or for other notification purposes as permitted by applicable law

• For the facility’s directory;

• That occurred pursuant to an authorization;

• For national security or intelligence purposes;

• To correctional institutions or law enforcement officials regarding patients in their custody; and

• As part of a limited data set which excludes your name, date of birth and other key identifiers.

The record of disclosures will include the date of each disclosure, who received the disclosed health information and this individual's address, if known, a brief description of the health information disclosed, and why the disclosure was made. We will provide the first list you request within a 12-month period at no charge. For additional lists, we may charge for the cost for providing the list.

Obtain a Paper Copy of this Notice. Upon your request, you may at any time receive a paper copy of this Notice, even if you earlier agreed to receive this Notice electronically. This Notice is available at the admissions desk of all our locations. It is also on our website at rogersbh.org.

Notified of a Breach. We are required by law to maintain the privacy of protected health information and you have the right to be notified if your unsecured protected health information has been the subject of a breach.

Complaint. If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint, call the Health Information Manager at (262) 646-6575, who will provide you with the necessary assistance and paperwork. You also have the right to complain to the Secretary of the Department of Health and Human Services at: Office for Civil Rights, 233 N Michigan Ave. Suite 240, Chicago, IL 60601, and-1-800-368-1019. If your complaint relates to your privacy rights while you are were receiving treatment, you may also file a complaint with the staff or administrator of Rogers Behavioral Health System. There will be no retaliation against you in any way for filing a complaint.

CONTACT INFORMATION

Again, if you have any questions or concerns regarding your privacy rights or the information in this Notice, please contact the Privacy Officer at (262) 646-1397.

The sites that follow this Notice include Rogers Memorial Hospital- Appleton, Brown Deer, Kenosha, Lincoln Center, Madison, Oconomowoc, Silver Lake, and West Allis. Email mailto: Media@rogersbh.org to request Notices of Privacy Practices for other states.

 

EFFECTIVE DATE

This notice is effective December 2015, unless and until it is revised.