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Patients > Notice of Privacy Practices


This Notice of Privacy Practices is effective as of April 14, 2003.
This Notice of Privacy Practices is for St. Nicholas Hospital’s departments and units, (such as Home Health & Hospice, Transitional Care Unit, Comprehensive Rehabilitation Inpatient Unit, and off-campus services all of which will be referred to as the “Hospital” in this Notice for convenience). It is also for healthcare professionals authorized to enter information in your Hospital charts, volunteers who are allowed to help you while you are in the Hospital and other Hospital personnel.

This Notice of Privacy Practices is required by regulations (the Privacy Rule) established under federal law (the Health Insurance Portability and Accountability Act).  This notice is intended to inform you about the ways in which St. Nicholas Hospital may use and disclose your protected health information (PHI) and to describe your rights and other obligations the Hospital has regarding the use and disclosure of your PHI.

The Privacy Rule requires the Hospital to make sure that your PHI is confidential and is neither disclosed to or used by anyone without your authorization or as specifically allowed by law.  The Privacy Rule requires the Hospital to give you this notice and to follow the terms of the notice that is currently in effect.  The Privacy Rule is lengthy and extremely complex.  This notice cannot be a complete and accurate account of the contents of the Privacy Rule.  If you would like a copy of the Privacy Rule or have questions about this Notice, please contact St. Nicholas’ Privacy Officer, 920-459-4652.

Our Pledge to You
We understand that PHI about you is personal.  We are committed to protecting PHI about you.  We create a record of the care and services you receive to provide quality care and to comply with legal requirements.  This notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor.  Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your PHI created in the doctor’s office.  We are required by federal and state law to keep PHI about you private.  Federal law requires us to give this notice of our legal duties and privacy practices with respect to PHI about you.  When state law is more protective of your PHI, we will abide by state law.  Some of these situations are noted below.  We will follow the terms of the Notice that is currently in effect unless stricter state law applies.

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Uses and Disclosures of your PHI
Without your written authorization, we can use your health information for the following purposes:

The Hospital may use PHI about you to provide you with medical treatment or services, to coordinate or manage your healthcare services, or to facilitate consultations or referrals as part of your treatment. For example, the Hospital may disclose your PHI to doctors, nurses, or other Hospital personnel who are involved in taking care of you.  Doctors involved in your treatment will need access to your PHI to determine if you have any chronic conditions or medical history that would affect your treatment.  Different departments of the Hospital also may share your PHI in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays.  The Hospital also may disclose your PHI to people outside the Hospital who may be involved in your medical care after you leave the Hospital, such as other healthcare facilities.

The Hospital may use and disclose your PHI to send bills and collect payment from you, your insurance company, or other third parties for the treatment and other services you may receive from the Hospital.  For example, the Hospital may need to give your health insurer, HMO, or PPO information about your treatment so they can pay the Hospital or reimburse you.  The Hospital may also tell your health insurer, HMO, or PPO about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.

Healthcare Operations
The Hospital may use and disclose PHI about you for Hospital operations.  These uses and disclosures are necessary to provide quality care to all Hospital patients and to facilitate the functioning of the Hospital, including, among other things:

quality assessment and improvement activities

activities relating to improving health or reducing healthcare costs

protocol development

care management

case coordination and related functions

competence and performance reviews

training, accreditation, certification, licensing, credentialing or other related activities

underwriting and other insurance related activities

medical review and auditing functions, including fraud and abuse detection and compliance programs

conducting or arranging for legal services

business planning and development

internal grievance resolution

business management and general administrative activities

creating “de-identified” health information

fund-raising for the Hospital’s benefit

some marketing activities

patient/client satisfaction surveys

For example, the Hospital may:

use PHI to review its treatment and services and to evaluate the performance of its staff in caring for you;

combine PHI about many Hospital patients to decide what additional services the Hospital should offer, what services are not needed, and to study the safety and effectiveness of treatments;

disclose information to doctors, nurses, and other Hospital personnel for training purposes;

combine its PHI with PHI from other hospitals and healthcare providers to compare how it is doing and find ways to make improvements in its care and the services it offers;

remove information that identifies you from a set of PHI so that others may use it to study healthcare and healthcare delivery without learning who the specific patients are;

use and disclose PHI to contact you as a reminder that you have an appointment;

use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you;

use and disclose PHI to tell you about health-related benefits or services that may be of interest to you.

The Hospital also may use and disclose limited PHI about you for certain fundraising, directory, and decision-making purposes, subject to your right to object to these uses or disclosures.

Hospital Directory (Registry)
The Hospital may list certain information about you (your name, where you are in the Hospital, a general description of your condition (e.g., treated and released, fair, good, critical) and your religious affiliation in a Hospital directory while you are a patient.  The Hospital can disclose this information, except for your religious affiliation, to people who ask for you by name, including to the media, newspapers, radio, etc.  Your religious affiliation may be given to members of the clergy even if they do not ask for you by name.  If you are receiving behavioral health treatment, you will not be identified in the directory without your written authorization.

Persons Involved in Your Care or Payment for Your Care
Unless you are receiving behavioral health treatment, we may disclose limited information about you to designated 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.  If family or friends are present while care is provided, we assume that they may hear the discussion unless you object. The Hospital may also disclose your PHI to an entity authorized to assist in disaster relief.

In the case of behavioral health treatment, with the exception of 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 verified by your treatment provider a summary of your diagnosis and prognosis; the medication list and treatment plan. 

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

In the case of behavioral 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

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 Your Rights Regarding Your PHI.

Fundraising Activities

The Hospital may use contact information (name, address and phone number and the dates you received treatment or services at the Hospital) from your PHI and may disclose contact information to a foundation related to the Hospital for fundraising purposes.  If you do not want the Hospital to contact you for its fundraising efforts please notify the Administrative Director, Fund Development 920-459-4714.

The Privacy Rule and Wisconsin LAW allow the Hospital to use or disclose your PHI without your authorization for a number of functions and activities, discussed below.

As Required By Law

The Hospital will disclose your PHI when required to do so by federal, state, or local law.

Public Health Risks
The Hospital may disclose your PHI for public health activities, including:

to prevent or control disease, injury or disability, to report births and deaths, and for public health surveillance or interventions;

to report child abuse or neglect;

to the FDA, to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by the FDA;

to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

to an employer to facilitate workplace medical surveillance as required by law;

Victims of Abuse, Neglect, or Domestic Violenc
The Privacy Rule authorizes the Hospital to notify the appropriate government authority if the Hospital believes a patient has been the victim of abuse, neglect or domestic violence.  The Hospital will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities
The Hospital may disclose PHI to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary activities, and other similar proceedings.  The Hospital may not disclose the PHI of a person who is the subject of an investigation that is not directly related to their receipt of healthcare or public benefits.  If you are a private pay patient, you may decide to opt out of this disclosure by making an annual request to do so.
Please refer to Your Rights Regarding Your PHI.

Judicial and Administrative Proceedings
The Privacy Rule allows the Hospital to disclose confidential PHI in response to a court or administrative order.  The Hospital may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, only if you agree to this disclosure or when required or authorized by law.

Law Enforcement
The Privacy Rule allows the Hospital to disclose PHI if asked to do so by a law enforcement official in the following circumstances:

In response to a court order, subpoena, warrant, summons, or similar process;

To identify or locate a suspect, fugitive, material witness, or missing person;

About the victim of a crime if, under certain limited circumstances, the Hospital is unable to obtain the person’s agreement;

About a death the Hospital believes may be the result of criminal conduct;

About criminal conduct at the Hospital; and

In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Wisconsin LAW generally requires a court order for the release of confidential PHI in these circumstances and may be considered more protective of your privacy than the Privacy Rule.  However, Wisconsin LAW does allow the release of PHI when a crime occurs on the premises and a victim is threatened with bodily harm.  Wisconsin LAW also requires that gunshot wounds or other suspicious wounds, including burns, that are reasonably believed to have occurred as the result of a crime, must be reported to the local police or sheriff.  The report must include the nature of the wound and the patient’s name.

Coroners, and Medical Examiners
The Hospital may disclose PHI to a coroner or medical examiner to identify a deceased person or determine the cause of death. 

Organ and Tissue Donation
The Hospital may disclose PHI to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.

Under certain circumstances, the Hospital may use and disclose your PHI for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of PHI, trying to balance the research needs with a patient’s need for privacy of his/her PHI.  Before the Hospital uses or discloses PHI for research, the project will have been approved through this research approval process.  The Hospital may, however, disclose your PHI to people preparing to conduct a research project; for example, to help them look for patients with specific medical needs, so long as the PHI they review do not leave the Hospital.  If you are a private pay patient, you may decide to opt out of this disclosure by making an annual request to do so. 
Please refer to Your Rights Regarding Your PHI. In some cases, a written authorization will be required for research. For example, where the researcher is not affiliated with us or if the researcher will have access to your name, address, or other information that reveals who you are or will be involved in your care at the Hospital.

Serious Threat to Health or Safety
If there is a serious threat to your health and safety or the health and safety of the public or another person, the Hospital may use and disclose your PHI to someone able to help prevent the threat. 

Specialized Government Functions
In certain circumstances, the Privacy Rule authorizes the Hospital to use or disclose your PHI to facilitate specified government functions.

Military and Veterans
The Hospital may disclose the PHI of armed forces personnel as required by military command authorities for the proper execution of a military mission.

National Security and Intelligence Activities
The Hospital may disclose your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. 

Protective Services for the President and Others
The Hospital may disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations.

Medical Suitability Determinations
The Hospital may disclose your PHI to the Department of State for use in making medical suitability determinations.

Inmates and Law Enforcement Custody
The Hospital may release the PHI of inmates and others in law enforcement custody to the correctional institution or law enforcement official, for the institution to provide you with healthcare to protect your health and safety or the health and safety of others for the safety and security of the correctional institution.

Workers’ Compensation
The Hospital may release your PHI for Workers’ Compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Authorization to Use or Disclose PHI
Other uses and disclosures of PHI not covered by this notice or the laws that apply to the Hospital will be made only with your written authorization.  If you authorize the Hospital to use or disclose your PHI, you may revoke that authorization in writing at any time except to the extent that the Hospital has already taken action in reliance on it.  If you revoke your authorization, the Hospital will no longer use or disclose your PHI as specified by the revoked authorization. 

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Your Rights Regarding Your PHI
You have the following rights regarding PHI the Hospital maintains about you:

Right to Request Restrictions
You have the right to request restrictions or limitations on the Hospital’s uses or disclosures of PHI about you for treatment, payment, or healthcare operations.  You also have the right to request a limit on the Hospital’s disclosure of your PHI to someone who is involved in your care or the payment for your care.

The Hospital is not required to agree to your request.
For example, some disclosures are mandated by Wisconsin Law.  If the Hospital does agree, it will comply with your request unless the information is needed for emergency treatment.  A request for restrictions should be made in writing by contacting the Hospital Privacy Officer at 920-459-4652.  In your request, please tell the Hospital (1) what information you want to limit; (2) whether you want to limit its use, disclosure, or both; and (3) to whom you want the limits to apply.

Right to Request Confidential Communications
You have the right to request that the Hospital communicate with you about medical matters through specific channels, that is, in a certain way or at a certain location.  For example, you can ask that the Hospital only contact you at work, home, or by mail.

A request for confidential communications should be made in writing to Hospital Privacy Officer.  The Hospital will not ask you the reason for your request, and must accommodate all reasonable requests.

Right to Inspect and Copy
You have the right to inspect and copy a designated set of your PHI.  This designated set typically includes medical and billing records, but may not include psychotherapy notes.

A request to inspect and copy this PHI should be made in writing to the Hospital Medical Records Department at 920-459-4657.  Please note that a request to inspect your PHI means that you may examine them at a convenient time or place.  If you request a copy of the information, the Hospital may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request.  The Hospital may deny your request to inspect and copy in certain circumstances as, for example, with respect to certain portions of a minor’s PHI, if you are a parent or legal guardian of a minor.  If you are denied access to your medical records, you may have the denial reviewed by a licensed healthcare professional chosen by the Hospital.  The person conducting the review will not be the person who denied your request.  The Hospital will comply with the outcome of the review. 

Right to Amend
If, in your opinion, your PHI is incorrect or incomplete, you may request that the Hospital amend your records.  You have the right to request an amendment for as long as the information is kept by or for the Hospital. 

A request for amendment of your PHI must be made in writing to the Hospital Privacy Officer at 920/459-4652.  A request to amend your PHI must give the reasons for the amendment.  The Hospital may deny your request for an amendment if it is not in writing or does not include a reason.  The Hospital may also deny your request for amendment if it covers PHI that:

were not created by the Hospital, unless the person who actually created the information is no longer available to make the amendment

are not part of the PHI kept by or for the Hospital

are not part of the information which you would be permitted to inspect and copy, as discussed above; or are accurate and complete

Right to an Accounting of Disclosures
You have the right to request an accounting of certain disclosures of your PHI by the Hospital.  This right does not extend to disclosures for purposes of: treatment, payment, healthcare 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.  A request for this accounting of disclosures should be made in writing to the Hospital Privacy Officer at 920-459-4652.  A request for accounting of disclosures must specify a time period.  We must comply with your request for the 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 a year.  The Hospital may charge for the additional accounting costs after notifying you of the cost involved and giving you the opportunity to withdraw or modify your request before any costs are incurred.

Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice at any time.  To obtain a paper copy of this notice, please contact Patient Registration,

You may obtain a copy of the current version of the Hospital’s Notice of Privacy Practices on its website,

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Amendments to this Notice
The Hospital reserves the right to amend this Notice at any time.  The Hospital is required to amend this Notice as made necessary by changes in the Privacy Rule.  Each version of the Notice will have an effective date on the first page.  The Hospital reserves the right to make the amended notice effective for PHI the Hospital has at the time the amendment is made, as well as any PHI the Hospital may receive or create in the future.  The Hospital will post a copy of the current notice in the Hospital.

If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the Department of Health and Human Services.  Complaints should be made in writing to the Hospital Privacy Officer.

You will not be intimidated, threatened, coerced, discriminated against, or otherwise retaliated against for filing a complaint.

For issues regarding patient privacy and the Privacy Rule contact our
Hospital Privacy Officer 920-459-4652.

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St. Nicholas HospitSt. Nicholas Hospital, 3100 Superior Avenue, Sheboygan, WI Ph:920-459-8300
 100 Superior Avenue
 Sheboygan, WI 53081