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Appleton Area Health

Your rights under the Health Insurance Portability & Accountability Act of 1996 (HIPAA)

How Your Medical Information May Be Used and Disclosed &

How You Can Get Access To This Information

If you have any questions about this notice, please contact the Facility Privacy Officer.




Who Will Follow This Notice of Privacy Practices (“Notice”): This Notice describes Appleton Area Health (the “Facility”) practices and that of:

  • Any health care professional authorized to enter information into your medical record maintained by the Facility

  • All departments and units of the Facility

  • Any member of a volunteer group allowed to help you while you are receiving services from the Facility

  • All employees, staff, agents and other Facility personnel

  • All entities, sites and locations within this Facility’s system will follow the terms of this Notice. They also may share medical information with each other for treatment, payment and health care operations purposes.


Our Pledge Regarding Medical Information: We understand that medical information about you and your healthcare is personal. We are committed to protecting medical information about you. A medical record is created to document the care and services you receive at this Facility. This record is needed to provide patient care and to comply with legal requirements. This Notice applies to all of the medical records of your care generated by the Facility. Your personal physician outside the Facility may have different policies or privacy notices regarding the physician’s use and disclosure of your medical information in the physician’s office or clinic.


This Notice will tell about the ways in which the Facility may use and disclose medical information about you. Also described are your rights and certain obligations we have regarding the use and disclosure of medical information.


The law requires the Facility to:

  • Make sure that medical information that identifies you is kept private;

  • Inform you 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.



The following categories describe different ways the Facility uses and discloses medical information. Each category will be explained. Not every possible use or disclosure will be listed. However, all the different ways the Facility is permitted to use and disclose information will fall within one of these categories.


  • Treatment. Your medical information may be used to provide you with medical treatment or services. This medical information may be disclosed to physicians, nurses, technicians, or other workforce members of the Facility who are involved in your care at the Facility. Your medical information may also be disclosed to healthcare students, interns and residents at the Facility.
    For example: A doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The doctor may need to tell the dietitian about the diabetes so appropriate meals can be arranged. Different departments of the Facility may also share medical information about you in order to coordinate your different needs, such as prescriptions, lab work and x-rays. The Facility also may disclose medical information about you to people outside the facility who may be involved in your medical care after you leave the Facility, such as family members, home health agencies, or others used to provide services that are part of your care. We will get your written consent prior to making disclosures outside of the Facility for treatment purposes, except in emergency circumstances when it is not possible to get your consent.

  • Payment. Your medical information may be used and disclosed so that the treatment and services received at the Facility may be billed and payment may be collected from you, the insurance company and/or a third party.
    For example: The health plan or insurance company may need information about the care you received from the Facility so they can provide payment for the costs of services. Information may also be given to someone who helps pay for your care. Your health plan or insurance company may also need information about a treatment you are going to receive to obtain prior approval or to determine whether they will cover the treatment. We will get your written consent prior to making disclosures for payment purposes. 

  • Health Care Operations. Your medical information may be used and disclosed for purposes of furthering day-to-day Facility operations. These uses and disclosures are necessary to run the Facility and to monitor the quality of care our patients receive.
    For example: Your medical information may be:

  1. Reviewed to evaluate the treatment and services performed by our staff in caring for you.

  2. Combined with that of other Facility patients to decide what additional services the Facility should offer, what services are not needed, and whether certain new treatments are effective.

  3. Disclosed to doctors, nurses, technicians, and other agents of the Facility for review and learning purposes.

  4. Disclosed to healthcare students, interns and residents.

  5. Combined with information from other facilities to compare how we are doing and see where we can improve the care and services offered. Information that identifies you in this set of medical information may be removed so others may use it to study health care and health care delivery without knowing who the specific patients are.

  6. Used to assess your satisfaction with our services.

  7. Used for population based activities relating to improving health or reducing health care costs.


We will get your written consent before making disclosures to others outside of the Facility for health care operations purposes.


  • Census Information: Limited information about you may be used in the Facility census report while you are a patient of the Facility. This information may include your name, location in the Facility, admission date and address.

  • Clergy Members: While you are a patient in the Facility, information about you may be disclosed to your specific clergy. This information may include your name, address, admission date, and religious affiliation.

  • Appointment or Prescription Reminders. Your medical information may be used to contact you by phone, electronic mail or regular mail, to remind you of an appointment you have for treatment or medical care at the Facility, or to inform you that a prescription is ready for you to pick up.  Unless you have requested we communicate with you in a different way, we may leave messages on your answering machine/voice mail or with a family member or other person that answers the phone if you are not home.  We will, however, make every effort to limit the information disclosed in these ways. If we receive any financial remuneration for making such communications beyond our costs of making the communication, we must first obtain your written authorization to make such communications.

  • Treatment Alternatives. Your medical information may be used to tell you about or recommend possible treatment options or alternatives that may be of interest to you. However, if we receive financial remuneration in exchange for making the recommendation, we will obtain your written authorization to make such recommendations.

  • Health-Related Benefits and Services. Your medical information may be used to tell you about health-related benefits or services that may be of interest to you.

  • Individuals Involved in Your Care.  We will only disclose medical information to those taking care of you, helping you to pay your bills, or other close family members of friends if these people need to know this information to help you, and then only to the extent permitted by law.  We may, for example, provide limited medical information to allow a family member to pick up a prescription for you.  Generally, we will get your written consent prior to making disclosures about you to family or friends.  If you are able to make your own health care decisions, we will ask your permission before using your medical information for these purposes.  If you are unable to make health care decisions, we will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so, including in an emergency situation.  They may be told about your condition unless you have requested additional restrictions.  In addition, your medical information may be disclosed to an entity assisting in a disaster relief effort so your family can be notified about your condition, status, and location. 

  • Fundraising.  We may use certain information (for example, name, address, telephone number or e-mail address, age, date of birth, gender, health insurance status, dates of service, department of service, treating physician or outcome information) to contact you for the purpose of raising money for this Facility and you will have the right to opt out of receiving such communications with each solicitation. For the same purpose, we may provide your name to our institutionally related foundation. The money raised will be used to expand and improve the services and programs we provide the community.  You are free to opt out of any such fundraising solicitation, and your decision will have no impact on your treatment or payment for services at this Facility.

  • Research. Under certain circumstances, your medical information may be used and disclosed for research purposes, either with your specific, written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins. 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 conditions. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, balancing the research needs with the patients’ need for privacy of their medical information. Your medical information may be disclosed in a limited way to people preparing to conduct a research project; for example, helping them look for patients with specific medical needs, so long as the medical information they review does not leave the Facility.  Minnesota law generally requires that we get your consent before we disclose your health information to an outside researcher.  We will make a good faith effort to obtain your consent or refusal to participate in any research study, as required by law, prior to releasing any identifiable information about you to outside researchers.

  • As Required by Law. Your medical information will be disclosed when required to do so by federal, state, or local authorities, laws, rules and/or regulations. In addition, we are required to report certain types of wounds, such as gunshot wounds and some burns.  In most cases, reports will include only the fact of injury, and any additional disclosures would require your consent or a court order.

  1. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, your medical information will be disclosed in response to a court or administration order, subpoena, discovery request, or other lawful process by someone else involved in the dispute when we are legally required to respond.

  2. Law Enforcement. Your medical information will be released if requested by a law enforcement official:

  • 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, we are unable to obtain the person’s agreement;

  • About a death we believe may be the result of criminal conduct;

  • About criminal conduct at our facility; 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.

  1. National Security and Intelligence Activities. Your medical information will be released to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

  2. Protective Services for the President of the United States and Others. Your medical information may be disclosed to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

  3. To Avert a Serious Threat to Health or Safety. Your medical information may be used and disclosed when necessary to prevent a serious threat to your health and safety and that of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

  4. Health Oversight Activities. Your medical information may be disclosed to a health oversight facility 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. Minnesota law requires that patient identifying information (for example, your name, social security number, etc.) be removed from most disclosures for health oversight purposes, unless you have provided us with written consent for the disclosure.

  • Private Accreditation Organizations. Your medical information may be used to fulfill this Facility’s requirements to meet the guidelines of private facility accreditation organizations such as Joint Commission, National Committee for Quality Assurance, etc.

  • Business Associates. There are some services provided in this Facility through contracts with business associates. Examples include attorneys, consultants, collection agencies, and information technology support services.  We may disclose information about you to our business associates so that they can perform the job we have contracted with them to do and bill you or your third-party payer for services rendered. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to redisclose the information unless specifically permitted by law.

  • Directory. We may include certain limited information about you in the Facility Directory while you are a patient at the Facility. The information may include your name, location in the Facility, your general condition (e.g., good, fair) and your religious affiliation if you provide this information to us. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the Facility Directory please request the Opt Out Form from the admission staff or the Facility Privacy Officer. 

  • Future Communications. We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our Facility is participating in. 


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

  • HIV, Substance Abuse, Mental Health and Genetic Information.  Special privacy protections apply to HIV-related information, alcohol and substance abuse, mental health, and genetic information. Some parts of this Notice may not apply to these kinds of protected health information. Please check with our Facility Privacy Officer for information about the special protections that do apply. For example, if we give you a test to determine if you have been exposed to HIV, we will not disclose the fact that you have taken the test to anyone without your written consent unless otherwise required by law.

  • Military and Veterans. If you are a member of the armed forces, your medical information may be released if we are required to do so by law, or when we have your written consent. If you are a member of the foreign military personnel, your medical information may be released to the appropriate foreign military authority.

  • Workers’ Compensation. If you seek treatment for a work-related illness or injury, we must provide full information in accordance with state-specific laws regarding workers’ compensation claims. Once state-specific requirements are met and an appropriate written request is received, only the records pertaining to the work-related illness or injury may be disclosed.

  • Public Health Risk. Your medical information may be used and disclosed for public health activities. These activities generally include the following:

  1. To prevent or control disease, injury or disability;

  2. To report births and deaths;

  3. To report child abuse or neglect; or abuse of a vulnerable adult;

  4. To report reactions to medications or problems with products;

  5. To notify people of recalls of products they may be using;

  6. 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;

  7. Reporting to the FDA as permitted or required by law; and

  8. To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.


  • Coroners, Medical Examiners, and Funeral Directors. Your medical information may be released to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the facility to funeral directors as necessary to carry out their duties. Other disclosures from your health record will require the consent of a surviving spouse, parent, person appointed by you writing or your legally authorized representative.

  • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for the following reasons:

  1. For the institution to provide you with health care;

  2. To protect the health and safety of you and others; and

  3. For the safety and security of the correctional institution.



  • Other Uses of Medical Information. Most uses and disclosures of psychotherapy notes, uses and disclosures of your protected health information for marketing purposes and disclosures that constitute a sale of your protected health information require your authorization prior to such use and disclosure.  Other uses and disclosures of medical information not covered by this Notice or the laws that apply to this Facility will be made only with your written authorization. If you provide the Facility authorization to use or disclose your medical information, you may revoke that authorization at any time by submitting a written revocation to our Facility Privacy Officer.  If you revoke your authorization, we will no longer use or disclose your medical information for the reasons covered in your written authorization. You understand that we are unable to take back any disclosures already made with your permission, and that we are required to retain our records of the care that the Facility provided to you, therefore disclosures that we made in reliance on your authorization before you revoked it will not be affected by the revocation.



  • Changes To This Notice. We reserve the right to change this Notice and 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. The Facility will post a current copy of the Notice with the effective date within the Facility as well as on its website. In addition, each time you are admitted to the Facility for care/services, as an inpatient or outpatient, we will offer you a copy of the current Notice in effect. 

  • Complaints. You will not be penalized for filing a complaint.  If you believe your privacy rights have been violated, you may file a complaint with the Facility or with the Secretary of the Department of Health and Human Services. To file a complaint with the Facility, contact the Facility Privacy Officer and/or follow the process outlined in this Facility’s Patient Rights documentation. All complaints must be submitted in writing.



You have the following rights regarding medical information the Facility maintains about you:


** NOTE: All Requests to Inspect and Copy Medical Information or to Receive an Electronic Copy of the Medical Information that May be Used to Make Decisions About You Must Be Submitted in Writing to the Facility Medical Records Department.**


Right to Inspect and Copy. You have the right to inspect and copy medical information that is maintained by this Facility and that is used to make decisions about your care.  Usually, this includes medical and billing records maintained the Facility.  You also have the right to request an explanation or summary of your medical information.  If your request is approved, we have thirty (30) days in which to respond to your request.  If we are unable to respond within thirty (30) days (for example, the records you have requested are stored off site), we may request an additional thirty (30) days in which to respond to your request.  You will receive written notice of this extension if needed and such notice will explain the reasons for the delay and the expected date of delivery.  We will respond to the request within a reasonable amount of time but no later than sixty (60) days from the date your written request is submitted to the Medical Records Department.  If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request, to the extent permitted by state and federal law.  If you request an explanation or summary of your medical information, we may charge a fee equal to the labor cost of compiling such explanation or summary.

If the Facility uses or maintains an electronic health record in one or more designated record sets with respect to your medical information, we must provide you with access to the electronic information in electronic form and the format requested, if it is readily producible, or, if not, in a readable form and format mutually agreed upon. You may direct the Facility to transmit the copy to another entity or person that you designate provided the choice is clear, conspicuous, and specific.  Your request must be submitted to the Facility Medical Records Department in writing; it must be signed by you; and it must clearly identify the designated person or persons and where to send the copy.


We may deny your request to inspect and copy in some limited circumstances (see below). If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional, other than the person who denied your request, will be chosen by the Facility to review your request and the denial. The Facility will comply with the outcome of the review.

  1. A licensed healthcare professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person.

  2. The protected health information makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person.

  3. The request for access is made by the individual’s personal representative, and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.

  4. The information requested is not maintained by our Facility.  In such situation, if we know the location of the information requested, we must provide that information to you.


  • 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 to information kept by or for the Facility.
    To request an amendment, your must submit a written request to the Facility Medical Records Department. You must also provide a reason that supports your request. Your request for an amendment may be denied if:

  1. Your request is not in writing or does not include a reason to support the request;

  2. The medical information was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

  3. The medical information is not part of the medical information kept by or for the Facility;

  4. The medical information is not part of the information you would be permitted to inspect and copy; or

  5. The medical information 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 your medical information for purposes other than treatment, payment and health care operations.To request this list or accounting of disclosures:

  1. You must submit your request in writing.

  2. Your request must state a time period for which you would like the accounting, which may not be longer than six years and may not include dates before April 14, 2003.

  3. 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 Request Restrictions. You have a right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care 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.  This restriction does not apply to uses or disclosures of your health information related to your medical treatment. To request restrictions, you must make your request in writing to the Facility Medical Records Department. In your request, you must tell us

  1. What information you want to limit;

  2. Whether you want to limit our use, disclosure or both;

  3. To whom you want the limits to apply (for example, disclosures to your spouse).


You also have a right to request that a health care item or service not be disclosed to your health plan for payment purposes or health care operations. We are required to honor your request IF the health care item or service is paid out of pocket and in full, unless you request a restriction on the information we disclose to a health maintenance organization and the law prohibits us from accepting payment from you above the cost-sharing amount for the item or service that is the subject of the requested restriction. Your restriction will only apply to records that relate solely to the service for which you have paid in full, We are not required to agree to any other request, and will notify you if we are unable to agree.  If we agree to your request, we must follow your restrictions (unless the information is necessary for emergency treatment). You may cancel the restrictions at any time.  In addition, we may cancel a restriction at any time, unless it relates to a health care item or service that is paid out of pocket and in full, as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.


  • Right to Request Confidential Communication. 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 the Facility Medical Records Department or Facility Privacy Officer. We will not ask you 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 a Paper Copy of This Notice.  You have the right to a copy of this Notice. You may ask us to give you a copy at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.


  • Right to Receive Notice of a Breach.  We are required to notify you by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), of any breach of your unsecured protected health information.


  • Facility Privacy Officer.  If you have any questions about this Notice, please contact the Facility Privacy Officer at:  320-289-8511.


Effective Date of Notice:  April 14, 2003


Revised on: ___09/05/2013

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