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.

St. Mary's Hospital Medical Center is required by federal and state law to maintain the privacy of your health information and federal law requires us to provide you with this notice describing our legal duties and privacy practices concerning your personal health information. When state law is more protective of your health information, we will abide by state law.

St. Mary's Hospital, together with its Medical Staff appointees and Allied Health Professionals is an Organized Health Care Arrangement (OHCA). As such, they share protected health information for the purposes of treatment, payment and health care operations at the hospital. In general, when we use or disclose your health information, we are obligated to use or disclose only the minimum amount of information necessary to achieve the purpose of the use or disclosure. However, this minimum necessary rule does not apply if the disclosure is to a provider regarding your treatment, to you, or due to a legal requirement.

We will abide by the privacy practices described in this notice, unless stricter state law applies, but reserve the right to change these practices in accordance with the law. Changes to our privacy practices would apply to all health information maintained by us. If we change our privacy practices, we will furnish you with a revised copy of our privacy notice upon request.

Without your written authorization, we can use your health information for the following purposes:

1. Treatment. The treatment selected will be documented in your medical record, so that other health care professionals can make informed decisions about your care. For example, a physician may use the information in your medical record to determine which treatment option, such as a drug therapy or surgery, best addresses your health needs.
2. Payment. In order for an insurance company or other health insurer to pay for your treatment, we need to submit a bill that identifies you, your diagnosis, and the treatment provided to you. As a result, we will pass such health information to an insurer in order to help receive payment for your medical bills.
3. Health Care Operations. We may need your diagnosis, treatment, and outcome information in order to improve the quality or efficiency of care delivered by us. These quality and efficiency improvement activities may include evaluating the performance of your physicians, nurses and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to similar situations.
   Appointment Reminders and Other Information. In addition, we may want to use your health information for appointment reminders. For example, we may view your medical record to determine the date and time of your next appointment with us, and then send you a reminder letter or call you to help you remember the appointment. We may also send you information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fundraising Activities. The Hospital may use your name, address and phone number to contact you to raise money for itself, and may disclose this contact information to a foundation related to the Hospital so that the foundation may contact you in raising money for the Hospital. If you do not want the Hospital to contact you for fundraising efforts please notify the Director of Fundraising at (920) 498 4365, St. Mary's Hospital Medical Center, 1726 Shawano Avenue, Green Bay, Wisconsin, 54303 3282.

Customer Service. The Hospital may contact you after your visit to learn how satisfied you were with our services. We may use information about what service you received during your stay to determine what survey to give you. Your responses will be combined with others for reporting purposes. We might contact you if you provide a specific comment about your service along with contact information on the survey. You may decline to participate in the survey by not responding; however, we strongly encourage you to participate in order to help us to improve our services.

4. Facility Directory. Unless you object, we may use your name, location in our facility, your general health condition (e.g., "stable," or "unstable"), and your religious affiliation for our directory. The information about you contained in our directory will be disclosed to people who ask for you by name while you are in the hospital and to clergy. However, the information about your religious affiliation will only be disclosed to clergy. If you are receiving behavioral health treatment, you will not be identified in the directory without your written authorization.
5. Others Involved In Your Care or Payment for Your Care. If family or friends are present while care is being provided, we will assume that they may hear the discussion unless you object. Unless you are receiving behavioral health treatment, we may disclose limited information about you to relatives, or close friends who are helping with your care or helping you pay your medical bills. Unless you provide written authorization, the information disclosed to these people will be limited to your location within our facility, your general condition, or death. You have the right to object to such disclosure, unless you are incapacitated or there is an emergency. In addition, we may disclose your health information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location or health status.
   In the case of behavioral health treatment, except drug and alcohol treatment programs, we may release the following health information from the treatment record to a spouse, parent, adult child or sibling, provided they are directly involved in, or are monitoring, your treatment and that authority has been verified by your treatment provider: a summary of your diagnosis and prognosis; the medication list; and the treatment plan.

Unless you have been judged incompetent, we will notify you about the release of this health information.

In the case of behaviorial health treatment, except for drug and alcohol treatment programs, we may: notify a spouse, parent or child that you are an inpatient; provide your attorney and guardian ad litem, as well as County Corporation Counsel, the patient’s health information to prepare for matters related to detention, admission or commitment; and release health information that would assist in the apprehension of a patient who has left the behavioral health unit without permission

You have the right to request a restriction on the above notifications. Please refer to Paragraph 3 under Your Health Information Rights.

6. As required by or permitted by law. In certain circumstances, we may have to report some of your health information to legal entities, such as law enforcement officials, court officials, or government agencies. Examples of such circumstances may be to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order in a judicial or administrative proceeding.
7. For public health activities. We may be required to report your health information to authorities to help prevent or control disease, injury, or disability. This may include using your medical record to report certain diseases, injuries, birth or death information, information related to the jurisdiction of the Food and Drug Administration, or information related to child abuse or neglect. We may also have to report certain work related illnesses and injuries to your employer so that workplace medical surveillance activities can be conducted.
8. For health oversight activities. We may disclose your health information to authorities for audit, investigation, inspection, licensure, disciplinary or other purposes related to oversight of the health care system or government benefit programs. If you are a private pay patient, you may decide to opt out of this disclosure by making an annual request to do so. See Paragraph 3 under Your Health Information Rights.
9. For activities related to death. We may disclose your health information to coroners, medical examiners and funeral directors so they can carry out their duties related to your death, such as identifying the body, determining cause of death, or in the case of funeral directors, to carry out funeral preparation activities.
10. For organ, eye or tissue donation. We may disclose your health information to entities involved in obtaining, banking or transplanting organs, eyes or tissue of cadavers for the purpose of facilitating donation or transplantation.
11. For research. Under certain circumstances and generally, only after a special approval process, we may use and disclose your health information to help conduct research. Such research might involve studies related to evaluating the effectiveness of a treatment. If you are a private pay patient, you may decide to opt out of this disclosure by making an annual request to do so. See Paragraph 3 under Your Health Information Rights. In some cases a written authorization will be required for research as, for example, where the researcher is not affiliated with us.
12. To avoid a serious threat to health or safety. As required by law and standards of ethical conduct, we may use or disclose your health information to the necessary authorities if we believe, in good faith, that such use or disclosure is necessary to prevent or minimize a serious and imminent threat to your health or safety or that of another individual or the public.
13. For military, national security, or incarceration/law enforcement custody. If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may disclose your health information to the proper authorities so they may carry out their duties under the law.
14. For worker's 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.
    Your Health Information Rights

You have several rights with regard to your health information. If you wish to exercise any of the following rights, please contact the Health Information Management Department at (920) 498 4586, St. Mary's Hospital Medical Center, 1726 Shawano Avenue, Green Bay, WI 54303-3282. Specifically, you have the right to:

1. Inspect and copy your health information. You have the right to inspect and obtain a copy of your health information. To do so, you must submit a written request. However, this right does not apply to psychotherapy notes or information compiled for judicial proceedings. In addition, we may charge you a reasonable fee if you want a copy of your health information.
2. Amend your health information. If you believe your health information is incorrect, you may ask us to amend the information. To request changes, you must make your request in writing to the Director of Health Information Management and give a reason as to why your health information should be changed. However, if we did not create the health information that you believe is incorrect, or if we disagree with you and do believe your health information is correct, we may deny your request.
3. Request restrictions on certain uses and disclosures. You have the right to notify us that you want restrictions placed on how your health information is used or to whom your information is disclosed. You also have a right to request a limit on the health information provided to family or friends involved in your care or payment of medical bills. You may want to restrict the health information provided to authorities involved with disaster relief efforts. However, it should be noted that we are not required to agree to your request. To request restrictions, you must make your request in writing to the Privacy Officer.
4. Request confidential communication of health information. You have the right to request alternative means or locations when we communicate your health information to you. For example, you may wish to receive information about your health status in a special, private room or that we only communicate with you by mail or at work. To request confidential communications, you must make your request in writing to the Privacy Officer, specifying how you wish to be contacted. We must accommodate reasonable requests.
5. Receive an accounting of disclosures of your health information. You have the right to request an accounting of certain types of disclosures of your health information. Not included in the accounting are disclosures made to you, or for purposes of: treatment, payment, health care operations, hospital directory, national security, law enforcement/corrections, and certain health oversight activities. The request for an accounting can include disclosures made during the previous six years, but the request cannot include dates before April 14, 2003. We must comply with your request for an accounting within 60 days, unless you agree to a 30 day extension, and we may not charge you for the accounting, unless you request such accounting more than once per year.
6. Obtain a paper copy of this notice. This Privacy Notice is available at St. Mary's Hospital Medical Center Website at www.stmgb.org. 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.
7. File a complaint. If you believe your privacy rights have been violated, you may file a complaint with us and/or with the Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, ILL. 60601 Voice Phone (312) 886-2359. FAX (312) 886-1807. TDD (312) 353–5693. To file a complaint with either entity, please contact Risk Management at (920) 498-4464, Quality Care Management Department, St. Mary's Hospital Medical Center, 1726 Shawano Avenue, Green Bay, Wisconsin, 54303-3282, who will provide you with the necessary assistance and forms.
   If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact the Privacy Officer at (920) 498-4575, Health Information Management Department, St. Mary's Hospital Medical Center, 1726 Shawano Avenue, Green Bay, Wisconsin, 54303-3282.

This Notice of Privacy Practices is Effective 04/14/03.