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Notice of Privacy

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.

The Notice of Privacy Practices applies to Tomah Memorial Hospital (TMH) and its personnel, volunteers, students, and trainees. The notice also applies to other health care providers that come to Tomah Memorial Hospital to care for patients such as physicians, physician assistants, therapists, other health care providers, emergency service providers, medical transportation companies, medical equipment suppliers, etc. that are not employed by the hospital who come to Tomah Memorial Hospital. These health care providers will follow this notice for information they receive about you from Tomah Memorial Hospital. These other health care providers may follow different practices at their own offices or facilities.

Tomah Memorial Hospital uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of TMH.

Protected Health Information means any information whether oral, electronic or paper, which is created or received
by TMH and relates to a patient's health care or payment for the provision of healthcare.

"Use" is the sharing of protected health information for treatment, payment, and healthcare operations.

"Disclosure" means the release of your protected health information outside of TMH. How TMH disclosures your information is outlined in this document.

HOW TMH MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

  • For Treatment: TMH will use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services to you, will record information in your record that is related to your treatment.

    This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how you respond to the actions.

  • For Payment: TMH may use and disclose your health information to third party payors for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to your insurance company or health plan. The information on the bill will contain information that identifies you, your diagnosis and treatment or supplies used in the course of treatment.

    If you have paid us out of pocket for health care services, you may request that we do not share information about that specific care with your health plan. Disclosures to your health plan made prior to your request and disclosures to your health plan for any subsequent care will not be affected.

  • For Health Care Operations: TMH may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel and others to:
    • evaluate the performance of our staff;
    • assess the quality of care and outcomes in your cases and similar cases;
    • learn how to improve our facilities and services; and
    • determine how to continually improve the quality and effectiveness of the health care we provide.
    • as federal/state law requires our facility to report. Examples include but are not limited to Bureau of Health Care Information, Vital Statistics, Cancer Reporting, Immunization Reporting, etc. which we consider to be part of our health care operations.

  • Business Associates: We may share your health information with third party "business associates: with whom we contract to assist us in treatment, payment or health care operations activities. Our business associates are required to protect your health information in accordance with this Notice and as required by law.

  • Patient Contacts: At times, TMH will use protected health information such as your name, address, etc. to contact you for:
    • provide appointment reminders.
    • provide information about treatment alternatives.
    • provide health-related benefits or services that may be of interest to you.
    • provide information to the TMH Foundation so they may contact you for fundraising efforts to benefit the hospital. You have a right to opt out of receiving fundraising communications.

  • Marketing: TMH will obtain an authorization prior to using your health information to inform you of products or services that we believe may be of interest to you. For example, we might contact patients receiving cancer treatment to notify them of the availability of an innovative treatment. There are some exceptions, which include communications promoting health in general that does not promote a product/service from a particular provider, communications about government/government-sponsored programs (i.e. Medicare, Medicaid), refill reminders and face-to-face communications by the CE to the individual.

  • Fundraising: We may use information found in your medical record, such as your name, address, phone number and treatment dates, to contact you for our fundraising purposes. For example, to provide more charity care or otherwise improve the health of this community, we may attempt to raise money; therefore, we may contact you to invite you to attend an event or to ask you for a donation. If we send you any fundraising materials, we will tell you how you may opt out of receiving future fundraising communications.

  • Required By Law: TMH may use and disclose information about you as required by law.

    For example, TMH may disclose information for the following:
    • for judicial and administrative proceedings pursuant to legal authority;
    • to report information related to victims of abuse, neglect or domestic violence; and
    • to assist law enforcement officials in their law enforcement duties.

  • Public Health: Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability or for other health oversight activities. For example, we must report certain disease, such as cancer, birth and death information and information of concern to the Food and Drug Administration.

  • Decedents: Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

  • Organ / Tissue Donation: If you are an organ donor, your health information may be used or disclosed for cadaver organ, eye, or tissue donation.

  • Research: TMH may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

  • Health and Safety: Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

  • Government Functions: Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services. If you are involved with military, national security or intelligence activities, are in custody of law enforcement officials, or are in inmate in a correctional institution, we may be required to disclose your health information to the proper authorities so they may carry out their duties under the law.

  • Workers' Compensation: Your health information may be used or disclosed in order to comply with laws and regulations related to Workers' Compensation.

  • TMH Directory: At the time of service, you may indicate your privacy preferences related to name, location, condition, and religion. The information about you contained in our directory will be released to people who ask for you by name. However, the information about your religious affiliation will only be disclosed to clergy if requested.

  • To Those Involved With Your Care: In an emergency situation where you are unable to function, health information may be disclosed to those involved in your care. You have the right to object to further disclosures when you are able to make your wishes known. In addition, we may release 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.

  • Other Uses: Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent TMH has taken action in reliance on such.

  • Copies: TMH may charge copies related to your medical record, depending on the purpose. Requests should be made at least twenty-four hours in advance during normal business hours by contacting Health Information Services.

  • Mental Health: Generally, the use or disclosure of psychotherapy notes requires the authorization of the patient. Further, Wisconsin law is more protective than HIPAA of certain types of health information, including information about a person's mental health and alcohol or drug treatment. We will only use or disclosure information about a patient's mental health treatment or alcohol or drug treatment as permitted or required by law, or as authorized by the patient.

  • Health Information Exchange: In compliance with federal and state laws, we may make your Protected Health Information available electronically through an electronic health information exchange to other health care providers and health plans that request your information for purposes of Treatment, Payment, and Health Care Operations; and to public health entities as permitted by law. Participation in an electronic health information exchange also lets us see other providers' and health plans' information about you for purposes of Treatment, Payment, and Health Care Operations. Your participation is voluntary; however, your health information will be included in this exchange unless you "opt out".

Opt out information is available through Tomah Memorial Hospital or at http://wishin.org/ForPatients/PatientChoice.aspx. This electronic health information exchange could include national information exchange when resources are available.Except for the situations listed above, we must obtain your specific written authorization for any other use or disclosure of your health information. This includes marketing activities conducted by third parties or where a third party seeks to purchase protected health information. If you authorize release of your health information, you may withdraw your authorization at any time.


YOUR HEALTH INFORMATION RIGHTS

You have the right to:

  • request a restriction on certain uses and disclosures for your health information. TMH must comply with request if the request is a disclosure to a health plan for purposes of carrying out payment or health care operations (but not treatment) and PHI pertains solely to a health care item or service for which the health care provider has been paid out of pocket in full.
  • obtain a paper copy of the notice of information practices upon request;
  • inspect and obtain a copy of your health record;
  • request that your health record be amended;
  • request communications of your health information by alternative means or at alternative locations;
  • receive an accounting of disclosures made of your health information.

Notification of Breach: If there should be a breach of your unsecured health information, we will notify you in a timely manner.

Contact our Privacy Officer for additional information in submitting the above requests.

COMPLAINTS

If you feel your privacy rights have been violated, you may contact:

Tomah Memorial Hospital
Attention: Privacy Officer
321 Butts Avenue
Tomah, WI 54660

Telephone Number: (608) 374-0311
or
We will provide you with information on how you can contact the Secretary of the Federal Department of Health and
Human Services.

You will not be retaliated against for filing a complaint.

OBLIGATIONS OF TOMAH MEMORIAL HOSPITAL

TMH is required by law to:

  • maintain the privacy of protected health information;
  • provide you with this notice of its legal duties and privacy practices with respect to your health information;
  • abide by the terms of this notice;
  • notify you if we are unable to agree to requested restrictions on how your information is used or disclosed;
  • accommodate reasonable requests you may make to communication health information by alternative means or at alternative locations; and

TMH reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you upon request, at your next visit, or at www.tomahhospital.org.

CONTACT INFORMATION

If you have any questions, please contact:

Tomah Memorial Hospital
Attention: Privacy Officer
321 Butts Avenue
Tomah, WI 54660

(608) 374-0311