Burnett Medical Center, Continuing Care Center, and Burnett Medical Center Clinic Privacy Practices Notice


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 PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.


Summary of Privacy Practices

Burnett Medical Center, Inc., Continuing Care Center, and Burnett Medical Center Clinic, (together referred to herein as "we") are participating in an Organized Health Care Arrangement and will use the joint notice of privacy practices ("Notice"). We are required by law (the Health Insurance Portability and Accountability Act of 1996, "HIPAA") to take reasonable steps to ensure the privacy of your protected health information ("PHI"), as defined by HIPAA. This Notice is being provided to inform you of the policies and procedures we have implemented and your rights under them, as well as under HIPAA. These policies are meant to prevent any unnecessary disclosure of your PHI.

Please review this entire Notice for details about the uses and disclosures we may make of your PHI, about your rights and how to exercise them, and about complaints regarding or additional information about our privacy practices.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your PHI. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect September 23, 2013, and will remain in effect unless we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of this Notice effective for all PHI that we maintain, including PHI we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice, post the revised notice at each of our service delivery sites, and make the new notice available to our patients and others upon request.

You may request a copy of this Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information at the end of this Notice.

Uses and Disclosures of PHI

Treatment: We may use your PHI, without your permission, to treat you. We may disclose your PHI, without your permission, to a physician or other health care provider for your treatment. These treatment activities include coordination of your care with other providers, with health plans and with others, consultation with other providers, and referral to other providers related to your care.

Payment: We may use and disclose your PHI, without your permission, to obtain or provide reimbursement for health care we provide to you, including submitting claims to health plans, other insurers or others. These payment activities include justifying our charges for and demonstrating the medical necessity of the care we deliver to you, determining your eligibility for health plan benefits for the care we furnish to you, obtaining precertification or preauthorization for your treatment or referral to other health care providers, participating in utilization review of the services we provide to you, and the like. We may disclose your PHI to another health care provider or to a health plan for that provider or plan to obtain payment or engage in other payment activities with respect to your health care.

We may need your written permission to disclose information taken from your mental health treatment records or HIV test results for payment purposes.

Health Care Operations: We may use and disclose your PHI for certain of our health care operations. Health care operations include, but are not limited to:

health care quality assessment and improvement activities;
reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing and credentialing activities;
conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention; and
business planning, development, management, and general administration, including customer service, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

Without your written permission, we may disclose your PHI to a health plan or another health care provider who is subject to federal privacy protection laws, as long as the provider or plan has or had a relationship with you and the PHI is for that provider's or plan's health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

We may need your written permission to disclose PHI or information taken from your mental health treatment records or HIV test results for certain health care operations.

Your Authorization: You may give us written authorization to use your PHI or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. The following uses and disclosures will be made only with your authorization: (i) most uses and disclosures of psychotherapy notes (if recorded by a covered entity); (ii) uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice.

Family, Friends, and Others Involved in Your Care or Payment for Care: We may disclose your name and location in our facilities without your written permission to a family member, friend or any other person you involve in your health care or payment for your health care. Before we disclose your name and location without your written permission, we will provide you with an opportunity to object. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing your name and location is in your best interest under the circumstances. We may use or disclose your name and location to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your health care in appropriate situations, such as a medical emergency or during disaster relief efforts.

With your written permission, we may disclose your PHI to a family member, friend or any other person you involve in your health care or payment for your health care. We will disclose only the PHI that is relevant to the person's involvement.

Facility Directories: Unless you object when we ask you, we may list your name, your religious affiliation, and your location in our facility in our facility directories. We will disclose your religious affiliation only to clergy. We will disclose the other information only to persons who ask for you by name.

If you are not present or are incapacitated or it is an emergency, we will use our professional judgment and any prior preference you may have expressed, to determine if listing your information in our facility directories is in your best interest. If we list your information, we will ask whether you object to continuing the listing as soon as you become available. We may not disclose your general medical condition or any information taken from mental health treatment records or HIV test results in our facility directories without your written permission.

Health-Related Products and Services: We may use your PHI to contact you to provide appointment reminders, and to communicate with you about treatment alternatives and other health-related benefits and services that may be of interest to you. These communications may describe health-related products or services that we provide, payment for such products or services, and the health care providers in a provider or health plan network.

Public Health and Benefit Activities: We may use and disclose your PHI, without your permission, when required by law, and when authorized by law for the following kinds of public health and interest activities, judicial and administrative proceedings, law enforcement, research, and other public benefit functions:

for public health, including to report disease and vital statistics, child abuse, and adult abuse, neglect or domestic violence;
to avert a serious and imminent threat to health or safety;
for health care oversight, such as activities of state licensing and peer review authorities, and fraud prevention enforcement agencies;
for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law;
in response to court and certain administrative orders and other lawful process;
to law enforcement officials with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons;
to coroners, medical examiners, and (with respect to HIV test results) funeral directors;
to organ procurement organizations by a hospital;
to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
as authorized by state worker's compensation laws.

HIV Test Results and Mental Health Records: We may not disclose HIV test results or mental health treatment records for certain of these purposes without your written permission, unless required by law. Your HIV test results, if any, may be disclosed as set forth in Wisconsin Statutes § 252.15(5)(a). A listing of the persons or circumstances set forth in that statute is available on request.

Fundraising: We may use certain information (name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information) to contact you for the purpose of raising money for Burnett Medical Center and you will have the right to opt out of receiving such communications with each solicitation. For the same purpose, we may provide your name to a business associate or related foundation to assist with our fundraising. The money raised will be used to expand and improve the services and programs we provide the community. You are free to opt out of fundraising solicitation, and your decision will have no impact on your treatment or payment for services at Burnett Medical Center.

Individual Rights

Access: You have the right to examine and to receive a copy of your PHI, with limited exceptions. You must make a written request to obtain access to your PHI. You should submit your request to the contact at the end of this Notice. You may obtain a form from that contact to make your request. The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained offsite. A single 30-day extension is allowed if we are unable to comply with the deadline.

We may charge you reasonable, cost-based fees for a copy of your PHI, for mailing the copy to you, and for preparing any summary or explanation of your PHI you request. Contact us using the information at the end of this Notice for information about our fees.

Disclosure Accounting: You have the right to a list of instances after April 13, 2003 in which we disclose your PHI for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities. You also have the right to a list of all written disclosures of your mental health treatment records.

You should submit your request to the contact at the end of this Notice. You may obtain a form from that contact to make your request. We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request and never for a disclosure that occurred before April 14, 2003. The accounting will be provided within 60 days from your submission of the request form. An additional 30 days is allowed if this deadline cannot be met. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to your additional requests. Contact us using the information at the end of this Notice for information about our fees.

Amendment: You have the right to request that we amend your PHI and mental health treatment records if you feel that such records are incorrect or incomplete. Your request must be in writing, and it must explain why the information should be amended. You should submit your request to the contact at the end of this Notice. You may obtain a form from that contact to make your request. We have 60 days after the request is made to make the amendment. A single 30-day extension is allowed if we are unable to comply with this deadline.

We may deny your request only for certain reasons. If we deny your request, we will provide you a written explanation. If we accept your request, we will make your amendment part of your PHI and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons you want to receive the amendment.

Restriction: You have the right to request that we restrict our use or disclosure of your PHI for treatment, payment or health care operations, or with family, friends or others you identify. We are not required to agree to your request. If we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law. You should submit your request to the contact at the end of this Notice. You may obtain a form from that contact to make your request. Any agreement we may make to a request for restriction must be in writing signed by a person authorized to bind us to such an agreement.

Confidential Communication: You have the right to request that we communicate with you about your PHI in confidence by alternative means or to alternative locations that you specify. You must make your request in writing. You should submit your request to the contact at the end of this Notice. You may obtain a form from that contact to make your request.

We will accommodate your request if it is reasonable, specifies the alternative means or location for confidential communication, and explains how payment for our services will be handled under the alternative means or alternative location you request for confidential communication of your PHI. We will not ask you to explain the reason for your request.

Electronic Notice: If you receive this Notice on our web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. Please contact us using the information at the end of this Notice to obtain this Notice in written form.

Out-of-pocket Payments Restrictions: You have the right to restrict certain disclosures of PHI to a health plan if you have paid out of pocket in full for the health care item or service.

Breach Notification of Affected Individuals: You have the right to be notified if there is a breach of your PHI.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us using the information at the end of this Notice.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, in response to a request you made to amend, restrict the use or disclosure of, or communicate in confidence about your PHI, you may complain to us using the contact information at the end of this Notice. You also may submit a written complaint to:

     Office for Civil Rights, DHHS
     233 N. Michigan Ave. - Suite 240
     Chicago, IL 60601
     (312) 886-2359; (312) 353-5693 (TDD)
     (312) 886-1807 FAX


We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Office:
     Privacy Officer, Burnett Medical Center
     257 W. St. George Avenue
     Grantsburg, WI 54840
     Telephone: (715) 463-5353