• Any health care professional authorized to enter information into your LMH chart
  
• Employees of the Hospital, Rosalia Gardens, hospital-employed physician offices, LeRoyer Hospice. All these related facilities, sites, and locations follow the terms of this notice and are included when the term “LMH” is used. In addition, these facilities, sites and locations may share medical information with each other for treatment, payment or health care operations purposes described in this notice.
  
• All departments and units of the hospital.
  
• Any member of a volunteer group we allow to help you while you are at LMH.
  
• All employees, staff, trainees and other LMH personnel.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive through LMH. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated through LMH, whether made by our personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic. If your personal doctor is employed by LMH, he or she will follow this notice regarding his or her use and disclosure of your medical information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private;
  
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
  
• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE (GIVE OUT) MEDICAL INFORMATION ABOUT YOU

The following categories describe the different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, students, or other personnel who are involved in your care through LMH. For example, a doctor treating you for a broken leg may need to know if you have other conditions, such as diabetes or cancer that may slow the healing process. In addition, the doctor may need to tell the dietician if you have diabetes or cancer, so that we can arrange for appropriate meals. Different departments of the hospital may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, rehab, and x-rays. We also may disclose medical information about you to people outside LMH who may be involved in your medical care after you leave the hospital, such as a family member, nursing home staff, or home care nurse.

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

For Health Care Operations. We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run LMH and make sure that all of our patients receive quality care. For example, we may use medical information:

• To review our treatment and services and to evaluate the performance of our staff in caring for you.
  
• To combine medical information about many LMH patients to decide what additional
  services LMH should offer, what services are not needed, and whether certain new treatments are effective
  
• To disclose information to doctors, nurses, technicians, medical students, and other LMH personnel for review and learning purposes.
  
• To combine the medical information we have with medical information from other hospitals to compare how we are doing and see whether we can make improvements in the care and services we offer.
  
• To remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders. We may use and disclose medical information about you to contact you as a reminder that you have an appointment for treatment or medical care through LMH.

Treatment Alternatives. We may use and disclose medical information about you to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose medical information about you to tell you about health-related benefits or services that may be of interest to you.

Baby’s First Book Program. For obstetrical patients of the hospital, the family resource librarian may use your address, phone number, date of delivery, sex of the baby and physician’s name for purposes of the “Baby’s First Book” program. Upon completion of the program, the resource librarian will send a certificate of completion and a final gift to you.

Facility Directory. We may include certain limited information about you in a facility directory while you are a patient at LMH. This information may include your name, location in the facility, general condition (e.g. fair, stable, etc.) and your religious affiliation. This directory information, except for your religious affiliation, may be given to people who ask for you specifically by name. Your religious affiliation may be given to a member of the clergy, such as a pastor or priest, even if they do not ask for you by name. If you do not want LMH to include your medical information in a facility directory, you must provide written notification to:

Langlade Memorial Hospital
Attention: Privacy Officer
Quality Resource Department
112 East 5th Ave.
Antigo, WI 54409

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or a family member who is involved in your medical care, as well as to persons involved in payment of your care. We may also tell your family or friends your condition and that you are at LMH.

We may give out medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

If you do not want LMH to disclose your medical information to such individuals, you must provide written notification to:

Langlade Memorial Hospital
Attention: Privacy Officer
Quality Resource Department
112 East 5th Ave.
Antigo, WI 54409

Fundraising Activities. We may use medical information about you (name, address and phone number and the dates you received treatment or services at the hospital) to contact you in an effort to raise money for LMH and its operations. We may disclose medical information to a foundation related to LMH so that the foundation may contact you in raising money for LMH. If you do not want LMH to contact you for fundraising efforts, you must provide written notification to:

Langlade Memorial Hospital
Community Health Foundation
112 East 5th Ave.
Antigo, WI 54409

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
Public Health Activities. We may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report births and deaths.
• To report child abuse or neglect.
• To report reactions to medications or problems with products.
• To notify people of recalls of products they may be using;
• To notify a person who may have been exposed to a communicable 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, and
• To the Office of Health Care Information to report specified health care data.

Victims of Abuse, Neglect or Domestic Violence. We may disclose medical information to notify the appropriate government authority if we believe a child or elder has been the victim of abuse, neglect or domestic violence.

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

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court order.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official:

• In response to a court order, and
• About certain deaths specified by law.

Coroners and Medical Examiners. We may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify the deceased person or to determine the cause of death.

Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye; or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Research. Under certain circumstances, we may use and disclose medical information about you 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 medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or give out medical information for research, the project will be approved through this research approval process. However, we may give out medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital. We will almost always ask for your specific permission 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.

To Avert a 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, we may use or disclose medical information about you to someone able to help prevent the threat.

Specialized Government Functions.

• Military and Veterans. If you are a member of the armed forces, we may give out medical information about you as required by military command authorities when authorized by law.
  
• National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  
• Protective Services for the President and Others. We may disclose medical information about you 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. We may give out your medical records to the Department of the State for use in determining medical fitness.
  
• Inmates. If you are an inmate of a correctional institution, we may release medical information about you to the medical staff or intake staff of the correctional institution or the Department of Corrections when authorized by law.
  
• Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we do not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.To request restrictions, you must make your request in writing to:

Langlade Memorial Hospital
Health Information Department
112 East 5th Ave.
Antigo, WI 54409

In your request, you must tell us (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, for example, you may want to limit the information to be given to your spouse.

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

To request confidential communications, you must make your request in writing to:

Langlade Memorial Hospital
Health Information Department
112 East 5th Ave.
Antigo, WI 54409

We will not ask the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Inspect and Copy. You have the right to inspect and receive a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and obtain a copy of this medical information, you must submit your request in writing to:

Langlade Memorial Hospital
Health Information Department
112 East 5th Ave.
Antigo, WI 54409

Please note that a request to inspect your medical records means that you may examine them at a convenient time and place. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for LMH.

To request an amendment, your request must be made in writing and submitted to:

Langlade Memorial Hospital
Health Information Department
112 East 5th Ave.
Antigo, WI 54409

In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support your request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  
• Is not part of the medical information kept by or for LMH;
  
• Is not part of the information which you would be permitted to inspect and copy; or
  
• Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of “disclosures”. This is a list of the disclosures we made of medical information about you other than disclosures made for purposes of treatment, payment, or health care operations, pursuant to your authorization and other disclosures that are not required to be included in this accounting.

To request this list or accounting of disclosures, you must submit your request in writing to:

Langlade Memorial Hospital
Health Information Department
112 East 5th Ave.
Antigo, WI 54409

Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a paper copy of this notice at the Health Information or Emergency Department within the hospital as well as at any admissions desk within the hospital or any other LMH service location.

Changes To This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a paper copy of the current notice in the hospital and in all other LMH service locations, as well as on our website. The notice will contain on the first page, in the top right-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with LMH or with the Secretary of the Department of Health and Human Services. To file a complaint with Langlade, submit a written statement to:

Langlade Memorial Hospital
Attention: Privacy Officer
Quality Resource Department
112 East 5th Ave.
Antigo, WI 54409
715-623-9317

You may also file a complaint with the:

Secretary of Health and Human Services
200 Independence Avenue SW
Washington, D.C. 20201

You will not be penalized or retaliated against for filing a complaint.

Other Uses of Medical Information.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.