Notice of Privacy Practices

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• You have the right to personal privacy and confidentiality of PHI (Protected Health Information) that is secure against loss, destruction or unauthorized use.
• Although your health record is the physical property of the healthcare facility that generated it, this information belongs to you.
• You have the right to request a restriction on certain uses or disclosures of your health care information, including disclosures to a family member or other person involved with your care or with payment for your care. We do not have to grant the restriction except if the disclosure restricted is to a health plan and you have paid for the health care item or service out-of-pocket or another has paid out of his/her pocket for you.
• You have the right to obtain orally and a paper copy of the Notice of Privacy Practices upon request.
• You have the right to access and review your record, at no charge, and purchase photocopies. You have the right to request that the copy be provided in an electronic form or format such as encrypted e-mail if it is readily producible. You must set up a time in advance with the facility.
• You have the right to know who has received your health information after 04/14/2003, except as provided by law.
• You have the right to request your health information by alternative means or in other locations to protect your privacy.
• You have the right to request an amendment to your protected health information. We will give you notice of our acceptance or denial of your request. You may be asked to make your request in writing and to give a reason as to why your health information should be changed.
• You have the right to be notified following a breach of unsecured protected health information.
• You have the right to refuse the release of personal and medical records, except when release is to the individual resident representative where permitted by applicable law, required by law, for treatment, payment or health care operations, and for public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

• This facility is required to maintain the privacy of your health information.
• To provide you with Notice of Privacy Practices concerning information we collect and maintain about you.
• To abide by the terms of this notice.
• To accommodate reasonable requests, you may have to communicate health information by alternative means or at alternative addresses or locations.
• We reserve the right to change our practices and to make the new provisions effective for all protected health information created or received before the effective date of the notice revision. Should our information practices change within the expiration date ("maximum of 1 year") of your signed authorization to release information, we will mail a revised notice to your last known address.
• We will not use or disclose your health information without your proper authorization, except for applicable state and federal laws.
• To notify you if you are affected by a breach of your unsecured health information.
• Fond du Lac County Notice of Privacy Practices can be found on our website at

1. Treatment: We will use your health information to provide you with treatment or services. For example, Your treatment team members might discuss your medical/health information to develop and carry out a plan for your services.
2. Payment: We will use your health information for payment and operations. For example, A bill might be sent to you or a third-party payor or we may receive a claim from your service provider. This may include information that identifies you, as well as procedures and supplies used.
3. Health Care Operations: We will use your health information for regular service operations. For example, case management staff, risk or quality improvement manager, or the quality improvement team may use information in your service record to assess the care and outcomes in your case. This information could be used to improve the quality and effectiveness of the services we provide.
4. Business Associates: There are some services provided in our organization through contracts with business associates or service providers. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do. To protect your health information, the business associate and his subcontractors are directly liable for compliance with the HIPAA Privacy and Security requirements and are subject to civil penalties.
5. Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy, except for religious affiliation, to other people who ask for you by name.
6. Notification: We may use or disclose information to notify or assist in notifying a family member, representative, or another person responsible for your care, your location, and general condition. Also, we may disclose 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.
7. Communication with Other Individuals: Health information will only be shared with other individuals if we have your written authorization or qualified under legal exemptions. We may contact you to provide appointment reminders. Health professionals, using their best judgment, may disclose to a family member, other relative or any person you identify, health information relevant to that person's involvement in your care or payment related to your care.
8. Research: Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.
9. Coroners/Medical Examiners: We may disclose health information to coroners, medical examiners and funeral directors consistent with applicable law to carry out their duties.
10. Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for tissue donation and transplant.
11. Food and Drug Administration: We may disclose to the FDA health information relative to adverse events concerning food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacement.
12. Workers Compensation: We may disclose your health information to the appropriate persons to comply with the laws related to workers' compensation or other similar programs. These programs may provide benefits for work-related injuries or illnesses.
13. Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
14. For Military, National Security or Incarceration/Law Enforcement: If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may disclose your health information to the proper authorities so they may carry out their duties under the law.
15. For Health Oversight Activities: We may disclose your health information to authorities for audit, investigation, inspection, licensure, disciplinary or other purposes related to oversight of the health care system or government benefit programs.
16. Fundraising: We may contact you to raise funds for the health care facility that you had services from but you have the right to opt-out of receiving such communication.
17. Required by Law: We may use and disclose your health information when it is required by law such as reporting child or elderly abuse.
18. Judicial Administrative Proceedings: We may disclose your health information in response to a court order.
19. Organize Health Care Arrangement: Our health care facilities and practitioners may participate in one or more organized health care arrangements (OHCA) pursuant to which we may share health information for quality improvement purposes.
20. Health Information Exchange: From time to time, as permitted by law, we may make your health information electronically available through an information exchange service to other health care providers, health plans, and health care clearinghouses that request your health information. Participation in information exchange services also lets us see their health information about you.

The examples noted below regarding the use and disclosure of your health information will need your written authorization:
• Most uses and disclosures of psychotherapy notes.
• Uses and disclosures of marketing purposes when the facility receives remuneration.
• Disclosures that constitute a sale of your health information.

Other uses and disclosures of your protected health information not covered by this Notice will be made only with your written authorization unless otherwise specified by law. You have the right to revoke your authorization in writing at any time by submitting a written revocation to our Medical Record Department. If you revoke your authorization, we will no longer be able to use or disclose your health information although we will be unable to take back any disclosures that we may have already made with your permission.

If you believe your privacy rights have been violated, you can file a complaint with Fond du Lac County at the office of the Director of Administration, Fourth Floor, City/County Government Center, 160 S Macy St., Fond du Lac, WI 54935, telephone (920) 929-3156. There will be no retaliation for filing a complaint.

Any person who believes that a covered entity is not complying with the requirements of HIPAA may file a complaint with the Secretary of Health and Human Services within 180 days of the occurrence.

Complaints may be filed in writing with the Office of Civil Rights, Region V, U.S. Department of Health and Human Services, 233 Michigan Ave., Suite 240, Chicago, IL 60601.

Phone: (312) 886-2359, Fax: (312) 886-1807, TTD: (312) 353-5693. Email:

Consumers will not be asked to waive their right to file a complaint to receive treatment or services and the filing of a complaint will not interfere with their health care. Office of Civil Rights 1-866-627-7748.