Your Health. Your Rights.

MMC Notice of Privacy Practice

1. Our Commitment to Your Privacy

We understand that medical information about you and your health is personal. Memorial Medical Center is dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding you and the treatment and services we provide to you to offer you quality care and to comply with certain legal requirements.

These records stay the property of Memorial Medical Center. However, we make the following commitment to you:

• To maintain the confidentiality of your medical information.
• To provide you with this notice of our privacy practices and legal obligations concerning your medical information.
• To follow the terms of our notice of privacy practices that is currently in effect.

To summarize, this notice provides you with the following important information:

• How we may use and disclose your medical information.
• Your privacy rights in regard to your medical information.
• Our obligations concerning the use and disclosure of your medical information. 

1. HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION

(IF YOU ARE RECEIVING BEHAVIORAL HEALTH SERVICES, PLEASE SEE LETTER C OF THIS NOTICE) 

We use and disclose medical information in many ways. The following categories describe the different ways in which we may use and disclose your medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Please note that not every use or disclosure is listed in each category. However, the different ways we are permitted to use and disclose your medical information will fall within one of the categories.

Treatment: Memorial Medical Center may use and disclose your medical information to treat you. For example, we may ask you to undergo laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. Many of the people who work for Memorial Medical Center may use or disclose your medical information in order to treat you or to assist others in your treatment. Additionally, we may disclose your medical information to others who may assist in your care, such as your physician(s), nurses, therapists, spouse, children or parents.   Physicians may share your medical information with other physicians to facilitate consultation, referral or follow-up as part of your treatment.

Payment:   Memorial Medical Center may use and disclose your medical information in order to bill and collect payment for the services and items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits) and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We may use and disclose your medical information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your medical information to bill you directly for services and items.

Health Care Operations:   Memorial Medical Center may use and disclose your medical information to operate our business. These uses and disclosures are important to ensure that you receive quality care and that our organization is well-run. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may use your information to conduct cost-management and business planning activities for our organization. Further, we may disclose your information to doctors, nurses, healthcare students, and other personnel of Memorial Medical Center for review and learning purposes.

Appointment Reminders:   Memorial Medical Center may use and disclose your medical information to remind you that you have an appointment.

Treatment Alternatives/Health-Related Benefits and Services:   Memorial Medical Center may use and disclose your medical information to inform you of treatment alternatives and/or health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may disclose medical information about you to a friend or family member if an emergent situation arises, for example, if you are unconscious or are unable to answer questions.

Fundraising:   It is the policy of Memorial Medical Center not to participate in fundraising activities.

Marketing:   We may use your medical information to make a marketing communication to you that (1) occurs in a face-to-face meeting with you; (2) concerns products or services of nominal value: or (3) concerns our health-related products or services or those of another party, provided that we tell you if we have received, or will receive any money or other remuneration for making the communication to you. If you don’t want to receive marketing communications (other than those that are in a newsletter or other general communication device), please contact the Privacy Officer.

For any other marketing communications, we will need your written authorization for release of information specifically for this purpose.

Facility Directory: We may include certain limited information about you in our facility directory while you are a patient. This information may include your name, location, your general condition and your religious affiliation. The directory information, except for your religious affiliation, may be released to family and friends who ask for you by name.   Your religious affiliation may be given to a member of the clergy even if they do not ask for you by name. If you do not want your information included in our directory, you should inform the registrar upon your admission to the hospital.

THE FOLLOWING CATEGORIES DESCRIBE ADDITIONAL CONDITIONS IN WHICH WE MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION:

Required by Law:   We will use or disclose medical information about you when required by applicable federal, state, or local law.

Public Health Activities:   Memorial Medical Center may disclose your medical information for public health activities including generally:

• To prevent or control disease, injury or disability;
• To maintain vital records, such as births and deaths:
• To report child abuse or neglect;
• To notify a person regarding potential exposure to a communicable disease;
• To notify a person regarding a potential risk for spreading or contracting a disease or condition;
• To report reactions to drugs or problems with products or devices;
• To notify appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose  this information if the patient agrees or we are required or authorized by law to disclose this information; and
• To notify your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Abuse, Neglect, and Domestic Violence:   We may disclose your medical information if we believe you are a victim of abuse, neglect, or domestic violence. Memorial Medical Center will only make this disclosure if you agree, or when required or authorized by law.

Health Oversight Activities:   Memorial Medical Center may disclose your medical information to a health oversight agency for activities authorized by law for appropriate oversight of the health care system, governmental benefit programs and regulatory or statutory compliance. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Administrative Proceedings: Memorial Medical Center may use and disclose your medical information in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your medical information in response to a discovery request, subpoena, or other lawful processes by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Law Enforcement:  Wisconsin law allows Memorial Medical Center to release confidential information to law enforcement officials in the following circumstances:

• Concerning a death we believe might have resulted from criminal conduct;
• Regarding criminal conduct at the hospital;
• In response to a warrant, summons, court order, subpoena or similar legal process;
• To identify/locate a suspect, material witness, fugitive or missing person; and
• In an emergency to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator).
• In all other circumstances regarding law enforcement, Wisconsin law requires a court order for the release of confidential medical information.

Coroners, Medical Examiners, and Funeral Directors: Memorial Medical Center may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation: We will use or disclose your medical information to organizations that handle organ and tissue procurement, banking, or transplantation as required by law.

Research:   Under certain circumstances, we may use and disclose medical information about you for research purposes.   We will always ask for your specific authorization if medical information that identifies you will be used or disclosed in connection with a research project.

Serious Threats To Health or Safety:   Memorial Medical Center may use and disclose your medical information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Specialized Government Functions:   Military and Veterans: Memorial Medical Center may disclose your medical information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. National Security and Intelligence Activities: In addition, Memorial Medical Center may disclose your medical information to federal officials for intelligence and national security activities authorized by law. Protective Service for the President and 

Others: We also may disclose your medical information to federal officials in order to protect the President, other officials, or foreign heads of state, or to conduct investigations.

Inmates: Memorial Medical Center may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (1) for the institution to provide health care services to you, (2) for the safety and security of the institution, and/or (3) to protect your health and safety or the health and safety of other individuals.

Workers’ Compensation:   Memorial Medical Center may release your medical information for workers’ compensation and similar programs established by law to provide benefits for work-related injuries or illness.

1. YOUR RIGHTS REGARDING YOUR BEHAVIORAL HEALTH SERVICE RECORDS MAINTAINED BY MEMORIAL MEDICAL CENTER, INC. – BEHAVIORAL HEALTH SERVICES 

 

When receiving behavioral health services, your medical records are protected by numerous Federal and State Regulations. Memorial Medical Center is responsible for maintaining and releasing behavioral health service records in pursuit of the regulation or code which will provide you with the most protection in regard to safeguarding the confidentiality of your medical record.

Memorial Medical Center’s Notice of Privacy Practices is based on the Federal Health Insurance Portability and Accountability Act (HIPAA). However, the confidentiality of patient behavioral health service records, including mental health and/or alcohol and drug abuse records maintained by this program are also protected by Federal Code of Regulations 42 – Part 2 (Confidentiality of Alcohol and Drug Abuse Treatment Records), Wisconsin Administrative Code HFS 92 (Confidentiality of Treatment Records), Wisconsin Statute Chapter 51.30 (Mental Health Act), Wisconsin Administrative Code HFS 94 (Patient Rights), and Federal Code of Regulations 45 – Part 160 and 162 (Health Insurance Portability and Accountability Act).   There are instances when Federal Code or Wisconsin statute is stricter than HIPAA law and may take precedence over HIPAA law.

No part of Behavioral Health Service records that contain any identifying information, whether direct or indirect, may be released or disclosed except when required by law. Exceptions may include, but are not limited to:

• The patient’s written authorization, or
• A disclosure made to medical personnel in a medical emergency; or
• Qualified personnel for research, audit, or program evaluation; or
• Patient who commits or threatens to commit a crime either at the program or against any person who works for the program; or
• In instances of suspected child abuse and/or neglect.

If you are being admitted to a behavioral health service and have questions regarding your privacy, please contact the Privacy Officer.

Violation of Federal or State law and regulations by a program under this heading is a crime. Suspected violations may be reported to the Privacy Officer or the United States attorney in the district where the violation occurred.

1. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding the medical information that we maintain about you:

Requesting Restrictions:    You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your medical information to individuals involved in your care or the payment for your care, such as family members and friends.

We are not required to agree to your request; however, if we do agree, we will comply with your request except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your medical information, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion: (1) the information you wish to limit; (2) whether you are requesting to limit our practice’s use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Restrict Release of Information for Certain Services: You have the right to restrict the disclosure of information regarding services for which you have paid in full and out of pocket. This information can be released only upon your written authorization.

Confidential Communications: You have the right to request that Memorial Medical Center communicate with you about your health and related issues in a certain manner, or at a certain location. For instance, you may ask that we contact you by mail, rather than by telephone, or at home rather than work.

In order to request a type of confidential communication, you must make a written request to the Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. Memorial Medical Center will accommodate reasonable requests. You are not required to give a reason for your request.

Inspection and Copies:   You have the right to inspect and obtain a copy of the medical information that may be used to make decisions about your care, including patient medical records and billing records. You must submit your request in writing to the Privacy Officer in order to inspect and /or obtain a copy of your medical information. You have a right to ask for a copy of your electronic medical record in paper or electronic format. Memorial Medical Center may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Memorial Medical Center may deny your request to inspect and/or copy in certain limited circumstances. However, you may request in writing a review of our denial. Reviews will be conducted by another licensed healthcare professional chosen by us, not by the person who denied your request.

Amendment:   You may ask Memorial Medical Center to amend your medical information if you believe it is incorrect or incomplete or ask us to include additional information in your medical record. You may request an amendment for as long as the information is kept by Memorial Medical Center.   To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide us with a reason that supports your request for amendment. Memorial Medical Center may deny your request if you fail to submit your request in writing or if the request does not include a reason.   Also, we may deny your request if you ask us to amend information that is:

• Accurate and complete
• Not part of the medical information kept by or for the organization
• Not part of the medical information which you would be permitted to inspect and copy; or
• Not created by Memorial Medical Center, or unless the individual that created the information is no longer available to amend the information.

Accounting of Disclosures:  You have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain disclosures our organization has made of your medical information excluding disclosures for the purpose of treatment, payment, or healthcare operations. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer. A request for an accounting of disclosures must state a time period that may not be longer than six (6) years and may not include dates before April 14, 2003. Your request should indicate in what format you want the list, either paper or electronic, or if you want a summary of the list. The first list you request within a 12-month period is free of charge, but Memorial Medical Center may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to a Paper Copy of This Notice:   You have the right to obtain a paper copy of this Notice at any time.   You will automatically receive a copy of this Notice during the Registration process upon your first visit to the Hospital.   After your first visit, a copy of our Notice of Privacy Practices will be available to you if you wish to receive one. You may also obtain a copy of the current version of our Notice of Privacy Practices. 

Right to Provide an Authorization for Other Uses and Disclosures:    Memorial Medical Center will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Most uses and disclosures of psychotherapy notes (private notes of a mental health professional kept separately from the medical record) require your authorization. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked in writing at any time. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your authorization.

Breach Notification: Memorial Medical Center will notify you if a breach of your protected health information has occurred.

Right to File a Complaint:   If you believe your privacy rights have been violated, you may file a complaint with Memorial Medical Center or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.   You will not be penalized for filing a complaint.

To file a complaint with Memorial Medical Center, please contact the Privacy Officer at the following address: Memorial Medical Center, 1615 Maple Lane, Ashland, WI 54806.

CHANGES TO THIS NOTICE

The terms of this notice apply to all records containing your medical information that is created or retained by us. We reserve the right to revise, change, or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of the information that we already have about you, as well as any of your medical information that we may receive, create, or maintain in the future. Our organization will post a copy of our current notice in the Hospital in a prominent location. You may request a copy of our most current notice during any visit to our organization.

QUESTIONS

If you have any questions about this Notice of Privacy Practices, please contact a Facility representative listed below:

COVERED ENTITIES AND PRIVACY OFFICIALS INCLUDED IN THIS DOCUMENT:

Memorial Medical Center, Inc.

Privacy Officer – (715) 685-5535

Compliance Officer – (715) 685-5514

Administration – (715) 685-5510

Click here to download and print a copy of the Non-Discrimination Accessibility Statement.

Memorial Medical Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Memorial Medical Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Memorial Medical Center provides free aids and services to people with disabilities to communicate effectively with us, such as: 

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages

If you need these services, contact Jennifer Johnson, Compliance Officer at 715-685-5516

If you believe that Memorial Medical Center has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Jennifer Johnson, Compliance Officer. You can file a grievance in person, by mail, email or fax. 

Mail:

Memorial Medical Center

Jennifer Johson, Compliance Officer

1615 Maple Lane

Ashland, WI 54806

Email:

jljohnson@ashlandmmc.com

Phone:

715-685-5516

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically, by mail or by phone. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Electronically through the Office for Civil Rights Complaint Portal:

Available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

Mail:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone:

1-800-368-1019, 800-537-7697 (TDD