ADMISSION AGREEMENT — ATTACHMENT F — PRIVACY PRACTICES
WVH–Chippewa Falls

2175 E. Park Ave.

Chippewa Falls, WI 54729

(715) 720-6775
Toll-free Fax (888) 966-8821	WVH–King

N2665 County Rd. QQ

King, WI 54946-0600

(715) 258-5586
Toll-free Fax (888) 966-8819	WVH–Union Grove

21425 G Spring St.

Union Grove, WI 53182

(262) 878-6702
Toll-free Fax (888) 966-8816

NOTICE OF PRIVACY PRACTICES

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.

We are required by law to protect the privacy of medical information about you and that identifies you. This medical information may be information about healthcare we provide to you or payment for healthcare provided to you. It may also be information about your past, present, or future medical condition.

We are also required by law to provide you with this Notice of Privacy Practices explaining our legal duties and privacy practices with respect to medical information. We are legally required to follow the terms of this Notice. In other words, we are only allowed to use and disclose medical information in the manner that we have described in this Notice.

We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all medical information that we maintain. If we make changes to the Notice, we will:

Post the new Notice in our common waiting areas.

Have copies of the new Notice available upon request.
(Please contact the facility Privacy Officer to obtain a copy of our current Notice at: King (715) 258-5586; Union Grove (262) 878-6700; Chippewa Falls (715) 720-6775.)

The rest of this Notice will:

Discuss how we may use and disclose medical information about you.

Explain your rights with respect to medical information about you.

Describe how and where you may file a privacy-related complaint.

If, at any time, you have questions about information in this Notice or about our privacy policies, procedures or practices, you can contact the facility Privacy Officer.

WE MAY USE AND DISCLOSE MEDICAL INFORMATION
ABOUT YOU IN SEVERAL CIRCUMSTANCES

We use and disclose medical information about members every day. This section of our Notice explains in some detail how we may use and disclose medical information about you in order to provide healthcare, obtain payment for that healthcare, and operate our business efficiently. This section then briefly mentions several other circumstances in which we may use or disclose medical information about you. For more information about any of these uses or disclosures, or about any of our privacy policies, procedures or practices, contact the facility Privacy Officer.

Treatment

We may use and disclose medical information about you to provide healthcare treatment to you. In other words, we may use and disclose medical information about you to provide, coordinate or manage your healthcare and related services. This may include communicating with other healthcare providers regarding your treatment and coordinating and managing your healthcare with others.

Payment

We may use and disclose medical information about you to obtain payment for healthcare services that you received. This means that, within the health department, we may use medical information about you to arrange for payment (such as preparing bills and managing accounts). We also may disclose medical information about you to others (such as insurers, collection agencies, and consumer reporting agencies). In some instances, we may disclose medical information about you to an insurance plan before you receive certain healthcare services because, for example, we may need to know whether the insurance plan will pay for a particular service.

Healthcare Operations

We may use and disclose medical information about you in performing a variety of business activities that we call “healthcare operations.” These “healthcare operations” activities allow us to, for example, improve the quality of care we provide and reduce healthcare costs. For example, we may use or disclose medical information about you in performing the following activities:

Reviewing and evaluating the skills, qualifications, and performance of healthcare providers taking care of you.

Providing training programs for students, trainees, healthcare providers or non-healthcare professionals to help them practice or improve their skills.

Cooperating with outside organizations that evaluate, certify or license healthcare providers, staff or facilities in a particular field or specialty.

Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients.

Improving healthcare and lowering costs for groups of people who have similar health problems and helping manage and coordinate the care for these groups of people.

Cooperating with outside organizations that assess the quality of the care others and we provide, including government agencies and private organizations.

Planning for our organization’s future operations. Resolving grievances within our organization.

Reviewing our activities and using or disclosing medical information in the event that control of our organization significantly changes.

Working with others (such as lawyers, accountants and other providers) who assist us to comply with this Notice and other applicable laws.

Persons Involved in Your Care

We may disclose medical information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care

We may also use or disclose medical information about you to a relative, another person involved in your care or possibly a disaster relief organization (such as the Red Cross) if we need to notify someone about your location or condition.

You may ask us at any time not to disclose medical information about you to persons involved in your care. We will agree to your request and not disclose the information except in certain limited circumstances (such as emergencies).

Required by Law

We will use and disclose medical information about you whenever we are required by law to do so. There are many state and federal laws that require us to use and disclose medical information. For example, state law requires us to report suspected elder abuse or neglect to the Department of Social Services. We will comply with those state laws and with all other applicable laws.

National Priority Uses and Disclosures

When permitted by law, we may use or disclose medical information about you without your permission for various activities that are recognized as “national priorities.” In other words, the government has determined that under certain circumstances (described below), it is so important to disclose medical information that it is acceptable to disclose medical information without the individual’s permission. We will only disclose medical information about you in the following circumstances when we are permitted to do so by law. Below are brief descriptions of the “national priority” activities recognized by law. For more information on these types of disclosures, contact the facility Privacy Officer.

Threat to health or safety: We may use or disclose medical information about you if we believe it is necessary to prevent or lessen a serious threat to health or safety.

Public health activities: We may use or disclose medical information about you for public health activities. Public health activities require the use of medical information for various activities, including, but not limited to, activities related to investigating diseases, reporting child abuse and neglect, monitoring drugs or devices regulated by the Food and Drug Administration, and monitoring work-related illnesses or injuries. For example, if you have been exposed to a communicable disease, we may report it to the State and take other actions to prevent the spread of the disease.

Abuse, neglect or domestic violence: We may disclose medical information about you to a government authority (such as a department of social services) if you are an adult and we reasonably believe that you may be a victim of abuse, neglect or domestic violence.

Health oversight activities: We may disclose medical information about you to a health oversight agency – which is basically an agency responsible for overseeing the healthcare system or certain government programs. For example, a government agency may request information from us while they are investigating possible insurance fraud.

Court proceedings: We may disclose medical information about you to a court or an officer of the court (such as an attorney). For example, we would disclose medical information about you to a court if a judge orders us to do so.

Law enforcement: We may disclose medical information about you to a law enforcement official for specific law enforcement purposes. For example, we may disclose limited medical information about you to a police officer if the officer needs the information to help find or identify a missing person.

Coroners and others: We may disclose medical information about you to a coroner, medical examiner, or funeral director or to organizations that help with organ, eye and tissue transplants.

Workers’ compensation: We may disclose medical information about you in order to comply with workers’ compensation laws.

Research organizations: We may use or disclose medical information about you to research organizations if the organization has satisfied certain conditions about protecting the privacy of medical information.

Certain government functions: We may use or disclose medical information about you for certain government functions, including but not limited to military and veterans’ activities and national security and intelligence activities. We may also use or disclose medical information about you to a correctional institution in some circumstances.

For a Facility Directory

The Wisconsin Veterans Home (WVH) may keep a roster and disclose certain information about you including your name, your general health status, and where you are located in a facility directory while you are at the Home. The WVH may disclose this information to people who ask for you by name. If you do not want the WVH-King to include your information in the directory, you must notify the social worker for your floor.

Authorizations

Other than the uses and disclosures described above (#1-6), we will not use or disclose medical information about you without the “authorization” – or signed permission – of you or your personal representative. In some instances, we may wish to use or disclose medical information about you and we may contact you to ask you to sign an authorization form. In other instances, you may contact us to ask us to disclose medical information and we will ask you to sign an authorization form.

If you sign a written authorization allowing us to disclose medical information about you, you may later revoke (or cancel) your authorization in writing (except in very limited circumstances related to obtaining insurance coverage). If you would like to revoke your authorization, you may write us a letter revoking your authorization and deliver it to your social worker. If you revoke your authorization, we will follow your instructions except to the extent that we have already relied upon your authorization and taken some action.

The following uses and disclosures of medical information about you will only be made with your authorization (signed permission):

☐ Uses and disclosures for marketing purposes.

☐ Uses and disclosures that constitute the sales of medical information about you.

☐ Most uses and disclosures of psychotherapy notes, if we maintain psychotherapy notes.

☐ Any other uses and disclosures not described in this Notice.

YOU HAVE RIGHTS WITH RESPECT TO MEDICAL INFORMATION ABOUT YOU

You have several rights with respect to medical information about you. This section of the Notice will briefly mention each of these rights. If you would like to know more about your rights, please contact the facility Privacy Officer.

Right to a Copy of This Notice

You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy of this Notice will always be posted in our common waiting areas. If you would like to have a copy of our Notice, ask the receptionist or unit clerk for a copy or contact the facility Privacy Officer.

Right of Access to Inspect and Copy

You have the right to inspect (which means see or review) and receive a copy of medical information about you that we maintain in certain groups of records. If we maintain your medical records in an Electronic Health Record (EHR) system, you may obtain an electronic copy of your medical records. You may also instruct us in writing to send an electronic copy of your medical records to a third party. If you would like to inspect or receive a copy of medical information about you, you must provide us with a request in writing. You may write us a letter requesting access and deliver it to your floor social worker.

We may deny your request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. We will also inform you in writing if you have the right to have our decision reviewed by another person.

If you would like a copy of the medical information about you, we will charge you a fee to cover the costs of the copy. Our fees for electronic copies of your medical records will be limited to the direct labor costs associated with fulfilling your request.

Please contact the facility Privacy Officer for a fee schedule.

We may be able to provide you with a summary or explanation of the information. Contact our Privacy Officer for more information on these services and any possible additional fees.

Right to Have Medical Information Amended

You have the right to have us amend (which means correct or supplement) medical information about you that we maintain in certain groups of records. If you believe that we have information that is either inaccurate or incomplete, we may amend the information to indicate the problem and notify others who have copies of the inaccurate or incomplete information. If you would like us to amend information, you must provide us with a request in writing and explain why you would like us to amend the information. You may write us a letter requesting an amendment and deliver it to your floor social worker.

We may deny your request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. You will have the opportunity to send us a statement explaining why you disagree with our decision to deny your amendment request and we will share your statement whenever we disclose the information in the future.

Right to an Accounting of Disclosures We Have Made

You have the right to receive an accounting (which means a detailed listing) of disclosures that we have made for the previous six (6) years. If you would like to receive an accounting, you may send us a letter requesting an accounting and deliver it to your floor social worker.

The accounting will not include several types of disclosures, including disclosures for treatment, payment or healthcare operations. If we maintain your medical records in an Electronic Health Record (EHR) system, your request may include disclosures for treatment, payment or healthcare operations. The accounting will also not include disclosures made prior to April 14, 2003.

If you request an accounting more than once every twelve (12) months, we may charge you a fee to cover the costs of preparing the accounting.

Please contact the facility Privacy Officer for a fee schedule.

Right to Request Restrictions on Uses and Disclosures

You have the right to request that we limit the use and disclosure of medical information about you for treatment, payment and healthcare operations. Under federal law, we must agree to your request and comply with your requested restriction(s) if:

Except as otherwise required by law, the disclosure is to a health plan for purpose of carrying out payment of healthcare operations (and is not for purposes of carrying out treatment); and,

The medical information pertains solely to a healthcare item or service for which the healthcare provided involved has been paid out-of-pocket in full.

Once we agree to your request, we must follow your restrictions (except if 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 as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.

You also have the right to request that we restrict disclosures of your medical information and healthcare treatment(s) to a health plan (health insurer) or other party, when that information relates solely to a healthcare item or service for which you, or another person on your behalf (other than a health plan), has paid us for in full. Once you have requested such restriction(s), and your payment in full has been received, we must follow your restriction(s).

Right to Request an Alternative Method of Contact

You have the right to request to be contacted at a different location or by a different method. For example, you may prefer to have all written information mailed to your work address rather than your current address.

We will agree to any reasonable request for alternative methods of contact. If you would like to request an alternative method of contact, you must provide us with a request in writing and give it to the facility Privacy Officer.

Right to Notification if a Breach of Your Medical Information Occurs

You also have the right to be notified in the event of a breach of medical information about you. If a breach of your medical information occurs, and if that information is unsecured (not encrypted), we will notify you promptly with the following information:

☐ A brief description of what happened;

☐ A description of the health information that was involved;

☐ Recommended steps you can take to protect yourself from harm;

☐ What steps we are taking in response to the breach; and,

☐ Contact procedures so you can obtain further information.

Right to Opt-Out of Fundraising Communications

If we conduct fundraising and we use communications like the U.S. Postal Service or electronic email for fundraising, you have the right to opt-out of receiving such communications from us. Please contact the facility Privacy Officer to opt-out of fundraising communications if you chose to do so.

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES

If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies

or procedures, you may file a written complaint either with us or with the federal government.

We will not take any action against you or change our treatment of you in any way if you file a complaint.

To file a written complaint with us, you may bring your complaint directly to the facility Privacy Officer, or you may mail it to the appropriate facility address:

Wisconsin Veterans Home	Wisconsin Veterans Home	Wisconsin Veterans Home

at King	at Union Grove	at Chippewa Falls

HIPAA Privacy Official	HIPAA Privacy Official	HIPAA Privacy Official

N2665 County Road QQ	21425 Spring Street	2175 Park Avenue

King, WI 54946-0605	Union Grove, WI 53182	Chippewa Falls, WI 54729

To file a written complaint with the federal government, please use the following contact information:

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F, HHH Building

Washington, D.C. 20201

Toll-Free Phone: 1-(877) 696-6775

Website: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

Email: OCRComplaint@hhs.gov

WDVA 4020F (08/13) Page 7 of 7	You can access the most recent version of this form

Templates\WDVA_4020F-Admission-Agreement-Attachment-F-Privacy-Practices.dot	from the WDVA website at www.WisVets.com/Forms.

WDVA 4020F (08/13) Page 1 of 1	You can access the most recent version of this form

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WDVA 4020F - Admission Agreement - Attachment F - Privacy Practices

Karen Emery

2013-07-24

Emery, Karen

Department of Veterans Affairs