To request a restriction you must complete a

• Other Uses and Disclosures of Your Information
Most uses and disclosures of psychotherapy
notes require your written authorization. Uses
and disclosures of your information for marketing
purposes and disclosures that constitute the
sale of your information require your written
authorization. Other uses and disclosures of your
information that are not described above will be
made only with your written permission. If you
provide the Hospital with an authorization, you
may revoke the authorization in writing, and this
revocation will be effective for future uses and
disclosures of your information. However, the
revocation will not be effective for information
that the Hospital has used or disclosed in
reliance on the authorization.
• Right to be Notified of a Breach
You have the right to be notified in the event
that the Hospital (or one of the Hospital’s
Business Associates) discovers a breach of your
unsecured information.
• Right to Request Restrictions
You have the right to request certain restrictions
of the Hospital’s use or disclosure of health
information for treatment, payment or health
care operations. You also have the right to
request a restriction on our disclosure of your
health information to someone who is involved
in your care or the payment for your care.
The Hospital is not required to agree to your
request if it interferes with patient care,
treatment, hospital/clinic operations and/or
payment of your bill.
If the Hospital does agree to the restriction,
it will comply with your request unless the
information is needed to provide you with
emergency treatment. The Hospital will agree
to restrict disclosure of your information to a
health plan if the purpose of the disclosure is for
payment or health care operations purposes
and your information pertains solely to a service
for which you have paid the Hospital in full. A
request for restriction must be made in writing.
To request a restriction you must complete a
request form that is available in patient care
areas or in the Medical Records Department.
• Right to Inspect and Copy
You have the right to inspect and receive
a copy of your health records. A request to
inspect your records may be made while you
are an inpatient to your nurse or physician, or
while you are an outpatient, to the Medical
Records Department. For copies of your health
information, requests must go to the Medical
Records Department. For billing information,
contact Patient Financial Services.
• Right to Amend
If you feel that health information we have
about you is incorrect or incomplete, you may
ask us to amend the information for as long as
the information is maintained by the Hospital.
Requests for amending your health information
should be made in writing to the Medical
Records Department. The Hospital will respond
to your request within 60 days after you submit
the written amendment request form.
• Right to an Accounting of Disclosures
You have a right to request an “accounting
of disclosures.” This is a list of those people
with whom the Hospital may have shared
your health information, with the exception of
information shared for purposes of treatment,
payment or health care operations or when
you have provided us with an authorization
to do so. For example, based on your health
information we may have shared your
information with the Cancer Registry. To request
an accounting of disclosures, you must submit
your request in writing to our Medical Records
Department. We will provide the list at no cost
once during each 12-month period. For any
additional requests, we may charge you a
fee for the cost of providing the list. We will
notify you of the fee and you may choose to
withdraw or modify your request at that time
before any costs are incurred.
• Right to Request Confidential Communications
You have the right to request that we
communicate with you about your health
information in a certain way or at a certain
location. For example, you can ask that we
contact you only at work or by mail. We will
accommodate all reasonable requests.
• Right to Revoke Authorization
Uses and disclosures of health information not
covered by this Notice or the laws that apply
to the Hospital will be made only with your
authorization. If you authorize the Hospital to
use or disclose your health information, you
may revoke that authorization in writing at
anytime. We are unable to take back any
disclosures we have already made with your
permission. To revoke an authorization you must
contact the Medical Records Department.
ight to Complain
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. To file a complaint
with the Hospital, contact the Privacy Officer. All
complaints must be made in writing. The Privacy
Officer will assist you in filing your complaint and
the necessary paper work. Filing a complaint will
not affect your care and treatment.
Important Note: We reserve the right to revise or
change this Notice. Each time you sign a consent
for treatment at a site covered by this Notice, a
copy of the Notice in effect at that time will be
available for you.
Effective Date: September 23, 2013
How to Contact Us
Privacy Officer................................... (414) 266-1773
Medical Records Department........ (414) 266-2100
Patient Financial Services................. (414) 266-6200
Secretary of Department of
Health and Human Services............ (877) 696-6775
4836-7793-4869, v. 1
C1943N (9/13)
Joint Notice of Privacy Practices
This information is available in Spanish. Please
ask a staff member if you need a copy. Esta
información esta disponible en español. Si
necesita una copia en español, pídala a un
miembro del personal.
Most patients of Children’s Hospital of Wisconsin
are children; when we refer to “you” or “your” in
this Notice, we refer to the patient. When we refer
to disclosures of information to “you,” we mean
disclosures to the patient, the patient’s parent,
guardian or other person legally authorized to
receive information about the patient.
This Notice applies to all patient health information
maintained by Children’s Hospital of Wisconsin, its
Medical Staff and its affiliates, including Children’s
Hospital of Wisconsin hospitals in Milwaukee and
Neenah, Surgicenter, specialty care clinics, primary
care clinics, urgent care clinics, Community
Services locations, as well as Children’s Specialty
Group and any other affiliate Children’s Hospital
of Wisconsin designates as part of its organized
health care arrangement for purposes of HIPAA for
services provided at any of its locations.
If you have any questions after reading this Notice,
please contact the Hospital’s Privacy Officer.
Each time you visit the Hospital, your physician
or other health care provider, a record of your
visit is made. Typically, this record contains
your symptoms, examination and test results,
diagnoses, treatment and billing-related
information. This Notice applies to all of the
records of your care generated by the Hospital
whether made by Hospital employees, agents or
your physician. Your physician may have different
policies or notices regarding the physician’s use
and disclosure of your health information created
in the physician’s private office.
We are required by law to maintain the privacy
of your health information and provide you with
this description of our privacy practices. We will
abide by the terms of this Notice.
• Treatment
We will use health information about you to
provide you with medical treatment or services.
We will disclose health information about
you to doctors, residents, nurses, technicians,
students in health care training programs, or to
Hospital personnel who are involved in taking
care of you. For example, a physician treating
you for a broken leg may need to know if you
have diabetes because diabetes might slow
the healing process. Different departments of
the Hospital also may share health information
about you in order to coordinate the different
things you need, such as prescriptions, lab
work and x-rays. We also may disclose health
information about you to people outside
the Hospital who provide your medical care
after you leave the Hospital. For example, a
physician that provides your care following your
hospital service will be provided information
about your care and treatment here.
• Payment
The Hospital will use and disclose your health
information to send bills and collect payment
from you, your insurance company, or other
payors, such as Medicaid, for the care,
treatment and other related services you
receive from the Hospital. We also may provide
your name, address, health care and insurance
information to other care providers (for
example, your physician) who bill for services
related to your care at the Hospital. We also
may tell your health insurer about a treatment
your physician has recommended in order to
obtain prior approval or to determine whether
your plan will cover the treatment.
• Health Care Operations
We may use and disclose health information
about you for Hospital business operations. These
uses and disclosures are necessary to run the
Hospital and make sure that all of our patients
receive quality care and cost-effective services.
For example, we may use health information
to review the quality of our treatment and
services, to develop new programs as part
of promoting health and to evaluate our
performance in caring for you.
We also may combine our health information
with health information from other hospitals
for our staff and students to improve our care
and services. In these instances, we remove
information that identifies you as an individual
from your health information.
When we use or disclose your health care
information, it may be to another organization
that assists us in operating our hospital or
clinics. For example, when your physician
dictates a summary of his or her visit with you,
an outside company types up the document
for our medical records. We have contracted
with these outside agencies, who are called
“business associates,” to keep any health care
information received from us confidential.
• Hospital Directory
When you are an inpatient, the Hospital may
list certain information about you such as
your name and room number in the patient
directory. The Hospital can disclose this
information to people who ask for you by
name. You may request that no information
contained in the directory be disclosed. To
restrict use of information listed in the directory,
please inform the admitting staff or your nurse.
They will assist you with this request.
• F uture Communications and Fundraising Activities
The Hospital may use your health information to
contact you to provide newsletters, information
about wellness programs or other services
available to you, or to raise money to support
Hospital programs. The Hospital may disclose
this contact information to the Children’s
Hospital of Wisconsin Foundation so that the
Foundation may contact you related to raising
money for the Hospital. If you do not want to
be contacted for fundraising efforts, you must
notify us in writing. Please contact our Privacy
Officer to help you with this request.
• Required or Permitted By Law
The Hospital is required by law to disclose your
health information in certain circumstances to:
ontrol or prevent a communicable disease,
injury or disability, to report births and deaths,
and for public health oversight activities or
- T he Food and Drug Administration (FDA), to
report adverse events or product defects,
to track products, to enable product recalls,
or to conduct post-market surveillance as
required by law.
state or federal government agency to
facilitate their functions.
eport suspected child abuse to law
enforcement agencies responsible to
investigate or prosecute abuse.
espond to a valid court order.
- T he Department of Health Services (DHS),
a protection or advocacy agency or law
enforcement authorities investigating abuse,
neglect, physical injury, death, violent crimes
involving suspicious wounds, burns, gunshot
wounds or death.
our court-appointed guardian or an agent
appointed by you under a health care power
of attorney.
rison officials if you are in custody.
orker’s Compensation officials if your injury
or illness is work-related.
• Organ, Eye and Tissue Donation
The Hospital will disclose health information to
organizations that obtain, bank or transplant
organs, eyes or tissue.
• Research
Under certain circumstances, the Hospital may
use and disclose your health information for
research purposes. For example, a research
project might compare the health and
recovery of all patients who received one
medication to those who received another for
the same condition. For this type of project, the
Hospital Privacy Board may waive the need
for consent and any published results would
not include information that identifies you. In
other circumstances, you will be asked to give
consent to participate in a research project.
You may choose not to participate in research.
Your care and treatment will not be affected
by your decision.
• Shared Medical Records/Health Information
The Hospital maintains your information in
electronic medical records and may allow
your health care providers from outside the
Hospital to access your information in the
Hospital medical records. In accordance with
applicable law, the Hospital may participate
in electronic health exchanges that facilitate
access to your information.
When sharing information with others outside
the Hospital, we share only what is reasonably
necessary unless we are sharing information
to help treat you, in response to your written
permission, or as the law requires. In these cases,
we share all the information that you, your
health care provider or the law has requested.