Hess Memorial Hospital

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.

Mile Bluff Medical Center is committed to protecting the privacy and security of your health information. If you have questions about the contents of this notice, please contact: Corporate Compliance Officer, Mile Bluff Medical Center, 1050 Division Street, Mauston, Wisconsin 53948, 608-847-6161.

Your Health Care Information - Protecting Your Privacy

It is your right as a patient to be informed of the privacy practices of your health care provider, as well as to be informed of your privacy rights with respect to your personal health information. This notice describes the privacy practices of Mile Bluff Medical Center, and the medical staff, departments, and personnel who provide you with care or services at any of our locations. We may share health information about you with each other, as necessary to provide you with treatment or health care services, obtain payment for services, or for our joint health care operations, all of which are described in more detail in this notice.

Who Will Follow Our Privacy Practices: Mile Bluff Medical Center provides care to our patients and residents, in

partnership with physicians and other professionals and organizations. Our privacy practices will be followed by:

Any of our health care professionals who care for you at any one of our locations or sites.

All locations, departments and units that are a part of our organization and staffed by our workforce, regardless of geographical location.

All members of our workforce, including employees, medical staff members, students, and volunteers.

Mile Bluff Medical Center (MBMC)’s Responsibilities

It is your right as a patient to be informed of MBMC’s legal duties with respect to protection of the privacy of your personal health information. MBMC is required to:

Maintain the privacy of your health information;

Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and

maintained about you; and

Follow the terms of our notice that is currently in effect.

We reserve the right to revise or amend our Notice of Privacy Practices. Any revisions or amendments to the Notice will be effective for all of your records created or maintained in the past as well as any records we create or maintain in the future. We will post the most current Notice in prominent locations on site and will be available at your request. We will also post the most current Notice at our organizational website, www.milebluff.com. You will be asked to acknowledge receipt of the Notice of Privacy Practices in writing during your first encounter.

HOW MBMC WILL USE & DISCLOSE YOUR HEALTH INFORMATION ABOUT YOU.

We are committed to ensuring that your health information is used responsibly by our organization. We collect health information about you and store it in paper records and computer files. We may use and disclose information about you without your written authorization for the following purposes:

For Treatment. We may use or disclose your health information for treatment purposes. While you are a patient at our organization, we may find it necessary to share your health information with other healthcare organizations that may participate in your care and treatments, such as a hospital where you may be transferred. Example: Your medical record will also be shared with Mile Bluff Clinic if you are being seen as an outpatient. Mile Bluff Medical Center and Mile Bluff Clinic, LLP have formed an Organized Health Care Arrangement (OHCA) for this purpose. Covered entities participating in the OHCA agree to abide by the terms of the notice with respect to health information created or received by the covered entity as part of its participation in the OHCA. Information for payment and health care operations as well as for your treatment can be shared between us.

For Payment: Mile Bluff Medical Center may use or disclose your health information to obtain reimbursement for the

provision of health care services. The bill may include information that identifies you, your diagnosis and your treatment. For example, we may use or disclose your information to your insurance company to obtain payment for the services you received. We may also contact your insurance company to determine if they will cover or pay for a certain treatment that they require prior authorization for.

For Health Care Operations: Your health information may be used for our organizational operations that are necessary to ensure that we provide the highest quality of care. For example, you health information may be used for performance improvement purposes.

Information Provided to You: We may use and disclose your health information to assist us in communicating appointment reminders, test results and treatment information. Our communications to you may be by phone or mail.

Fundraising Activities: We may want to use your information found in your medical record, such as your name, address and phone number to contract you for our fundraising purposes. For example, in order to provide more charity care or otherwise improve the health of your community, we may want to raise additional money and therefore may contact you for a donation.

Facility/Patient Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. If you do not want to be listed in the directory or for your information to be given out, you must notify one of our staff members that you object to this practice.

Notification and Communication with Family and Friends: Your health information may be disclosed to notify a family member, your personal representative or other person responsible for your well being about your location, your general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communicating with your family and others.

Research: Mile Bluff Medical Center may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law. Such research might try to find out whether a certain treatment is effective in curing an illness.

Required By Law: Mile Bluff Medical Center may have to report some of your health information to legal entities such as law enforcement officials, court officials, or government agencies. The use or disclosure will comply with and is limited to the relevant requirements of the law. Uses and disclosures required by the federal privacy rule and limited by the more protective requirements of state law include the following: Disclosures about victims of elderly or child abuse; disclosures for judicial and administrative proceedings; or disclosures for law enforcement purposes.

Organ and Tissue Donation: We may disclose health information to people involved with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.

Specialized Government Functions: We may disclose health information for specialized government purposes which include: Military and veterans activities, national security and intelligence activities, protective service of the President/others, medical suitability determinations for Department of State officials, correctional institutions and law enforcement custody situations, or provision of public benefits.

Public Safety: We may disclose your health information to governmental agencies in order to prevent or assist when there is a serious threat to the health or safety of others or the general public.

Workers' Compensation: We may release health information about you for workers' compensation. These programs provide benefits for work-related injuries or illness.

Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting births and deaths; reporting child or elder abuse or neglect;

reporting reactions to medications or problems with products; notifying people of recalls of products they may be using; notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; reporting domestic violence.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure and disciplinary actions. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceedings. If you are involved in a lawsuit or other administrative proceeding, we may release your health information in response to a court or administrative order.

Law Enforcement: MBMC may disclose your protected health information, except for HIV test results, to county law enforcement officials for the reporting and investigation of elderly and/or child abuse. MBMC may disclose your protected health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results, to state and federal law enforcement officials. MBMC may disclose mental health, alcohol or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. We may disclose your protected health information to a law enforcement official in response to a court order.

Coroner, Medical Examiner and Funeral Director: We may disclose your health information to coroners, medical examiners or funeral directors. This may be necessary, for example, to identify a deceased person or determine the cause death.

Correctional Institutions: If you are an inmate of a correctional institution, we may disclose to the institution your health information necessary for your health and the health and safety of others.

OTHER USES OF YOUR HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice as noted above, we will ask for your written authorization before using or disclosing information about you. If you choose to authorize disclosure of information about you, you can later revoke that authorization at any time by notifying us in writing about your decision.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.

As a patient of the Mile Bluff Medical Center you have certain rights with regard to the health information that is maintained

by our organization. These rights are as follows:

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or MBMC’s payment or health care operation activities. This request shall be made to the Health Information Department. We will consider your request, however, MBMC is not required to agree to your requested restriction. For example, you could ask that we not use or disclose information about a surgery you had.

Right to Request Confidential Communications: You have the right to request that we communicate your health information to you by alternative means or at alternate locations. Mile Bluff Medical Center shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your medical record.

Right to Inspect and Copy: You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be submitted in writing to the Health Information Department. This right may not apply to certain types of psychotherapy notes. If you request a copy of your health information, Mile Bluff Medical Center may charge you a reasonable fee for the costs of copying, mailing, or other related supplies associated with your request. For example, you may request a copy of your last visit to your family physician.

Right to Request to Amend: You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. This request may be made to the Health Information Department. You may be asked to make this request in writing and state the reason why your health record should be changed. If Mile Bluff Medical Center did not create the health information you believe is incorrect, or if Mile Bluff Medical Center disagrees with you, we may deny your request. For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended.

Right to an Accounting of Disclosure: You have the right to request a list or accounting of those disclosures, which Mile Bluff Medical Center has made regarding your health information for purposes other than treatment, payment, healthcare operations, information provided directly to you, information included in facility directory listings, and information disclosed as a result of mandated government functions. Your request shall be made to the Health Information Department and must state the time period desired for the accounting, which must be less than a six year period starting after April 14, 2003. The first accounting, in a 12-month period will be free; other requests may be charged according to our cost for producing the information. For example, you may request an accounting of disclosures made from your health record in the last year to the State for disease reporting.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice upon request. For example, if you received this notice electronically, you may request that we provide a paper copy of the notice.

PATIENT COMPLAINT PROCESS

If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about your access to your health information, you may file a complaint with Mile Bluff Medical Center or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint.

To file a complaint with Mile Bluff Medical Center, please contact the Mile Bluff Medical Center’s Corporate Compliance Officer who will provide you with the necessary assistance.

Effective Date: This Notice of Privacy Practice is effective as of April 14, 2003.

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