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 carefully.
This Notice is effective on August 1, 2013.
I. Who We Are
This Notice describes the privacy practices of Marshfield Clinic and Family Health Center of Marshfield, Inc. Together, these legally separate entities have formed an Organized Health Care Arrangement, or “OHCA”,
which allows them to manage care in an efficient and patient-friendly manner. Marshfield Clinic and Family Health Center of Marshfield, Inc., are referred to as “we” or “our” below.
II. Our Privacy Obligations
We have long been committed to protecting patient privacy. As part of this commitment, we follow federal and state law which requires us to maintain the privacy of your health information and to provide you with
this Notice of our privacy practices. When we use or disclose your health information, we are required to follow the privacy practices described in this Notice (or other notice in effect at the time of the use or
We must follow either federal or state law, whichever is more protective of your privacy rights. For example, if federal law allows certain disclosures of your health information without your written authorization,
but state law does require your written authorization for such disclosures, we must follow state law.
We reserve the right to change the privacy practices described in this Notice at any time. Changes to our privacy practices would apply to all health information we maintain. If we change our privacy practices,
we will post the new notice on our website at www.marshfieldclinic.org or make it available to you.
III. When We May Use and Disclose Your Health Information With Your Written Authorization
Use or Disclosure With Your Authorization. For any purpose other than the ones described below, we may use or disclose your health information only when you give us your written authorization to do so. For
example, we cannot send your health information to your life insurance company or sell your health information without your authorization.
Marketing. We must also obtain your written authorization before using your health information to send you any marketing materials. We can provide you with marketing materials in a face-to-face encounter or
a promotional gift of very small value, if we so choose. We may communicate with you about products or services relating to your treatment, to coordinate or manage your care, or provide you with information about
different treatments, providers or care settings.
Uses and Disclosures of Your Highly Confidential Information. Federal and state law require special privacy protections for certain highly confidential information about you
(“Highly Confidential Information”), including the part of your health information that is: (1) maintained in psychotherapy notes; (2) about treatment of mental illness or developmental disability; (3) about the
identity, diagnosis, prognosis, or treatment for alcohol or drug dependency; (4) about HIV test results; or (5) about child abuse or neglect. Except for certain treatment purposes described in Section IV below, we
will generally obtain your written authorization for uses or disclosures of Highly Confidential Information for the purposes described in Section IV. The only exception to this is if we are allowed by law to disclose
your Highly Confidential Information for certain purposes without your written authorization. For example, we are allowed to disclose information about treatment of mental illness or developmental disability for
program monitoring and evaluation, or to a physician in a medical emergency.
IV. When We May Use and Disclose Your Health Information Without Your Written Authorization
Treatment. We may use and disclose your health information to provide treatment and other services to you. For example, a doctor may use the information in your medical record to diagnose your injury or illness
and determine which treatment option, such as medication or surgery, best addresses your health needs. In addition, we may use your health information for appointment reminders or to send you information about
treatment alternatives or other health-related benefits and services that may be of interest to you. We may disclose your health information to other health care providers involved in your treatment.
Payment. We may use and disclose your health information to obtain payment for services that we provide to you. For example, in order for an insurance company to pay for your treatment, we must submit a bill
that identifies you, your diagnosis, and the treatment provided to you. As a result, we will provide such health information to an insurer to obtain payment for your medical bills. We may also disclose your health
information to another health care provider or health plan for its payment activities – for example, for the health plan to determine your eligibility or coverage.
Health Care Operations. We may need to use your health information to improve the quality or cost of care we deliver. These quality and cost improvement activities may include using your health information
to evaluate the quality of our health care services or sharing your health information with our Nurse Liaisons to ensure that you have a comfortable visit with us. We may also disclose your health information to
another health care provider or health plan that has or had a relationship with you for their health care operational activities such as for the other health care provider or health plan to evaluate the performance of
your doctors, nurses and other health care professionals.
Shared Medical Record/Health Information Exchange. We participate in a regional arrangement of health care organizations, who have agreed to work with each other, to facilitate access to health information
that may be relevant to your care. For example, if you are admitted to a hospital on an emergency basis and cannot provide important information about your health condition, this regional arrangement will allow us to
make your health information from other participants available to those who need it to treat you at the hospital. When it is needed, ready access to your health information means better care for you.
We store health information about our patients in a joint electronic medical record with other health care providers who participate in this regional arrangement. The participants may share or have access to your
health information through the joint electronic medical record for purposes described in this Notice. You may contact the Privacy Officer at telephone number 1-866-268-9199 to request a list of health care providers
who participate in the joint electronic medical record.
Disclosures to Business Associates. In order for us to carry out treatment, payment or health care operations, we may disclose your health information to persons or organizations that perform a service for
or on our behalf that requires the use or disclosure of individually identifiable health information. Such persons or organizations are our business associates. For example, we may disclose your health information to
an agency that accredits health care organizations or to a collection agency to collect payment of medical bills.
Disclosure to Relatives, Close Friends and Other Caregivers. In certain limited situations, we may disclose important health information to people such as your family members, relatives, or close friends who
are helping care for you or helping you pay your medical bills. The information disclosed may include the information that we believe is directly relevant to their involvement in your care or payment for your medical
bills, and may include your location, general condition or death. We will ask you if you agree to such a disclosure, unless you are unable to function or there is an emergency. If you are unable to function or there
is an emergency, we will disclose your health information if we determine it would be in your best interest. We may disclose applicable health information to family members and others who were involved in a decedent’s
care or payment for care prior to the patient’s death, unless doing so is contrary to the decedent’s prior expressed preference made known to us. In addition, 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.
Fundraising Communications. We may contact you to request a tax-deductible contribution to support our activities. If we conduct fundraising, we may share demographic and other information about you (such as
your name, address, phone number, dates and departments of service), with our fundraising staff without your written authorization. If you do not want to receive further fundraising communications, please contact
Marshfield Clinic by mail at 1000 N. Oak Avenue, Attn: Development-1R1, Marshfield, WI 54449; or, by email at email@example.com; or, by phone at 715-387-9249 or 1-800-858-5220.
Public Health Activities. If required or allowed by law, we may disclose your health information for the following public health activities: (1) to report health information to public health authorities for the purpose of
preventing or controlling disease, injury or disability; (2) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (3) to alert a person who may have been
exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; or (4) to report information to your employer as required by laws addressing work-related illnesses and
injuries or workplace safety.
Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence and the reporting of such information is required or allowed by law, we may disclose your health
information to a governmental authority, including a social service or protective services agency.
Health Oversight Activities. As required or allowed by law, we may disclose your health information to a government agency that is legally responsible for overseeing the health care system and is responsible for ensuring
compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings. We may disclose your health information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
Law Enforcement Officials. We may disclose your health information to the police or other law enforcement officials as required or allowed by law.
Coroners, Medical Examiners and Funeral Directors. We may disclose your health information to a coroner, medical examiner or funeral director as required or allowed by law.
Organ and Tissue Donation. We may disclose your health information to organizations that facilitate organ, eye or tissue donation, banking or transplantation.
Research. There are situations when researchers and research staff may use or disclose your health information for research purposes without your authorization. Researchers may conduct research that simply involves
reviewing your health information and the health information of others with similar conditions or diseases. In such situations, researchers will not contact you for your authorization, but must obtain permission from
a board (called the Institutional Review Board) that is in place to ensure that the welfare and privacy of research participants is protected as required by law. Researchers may also review your health information to
determine if there are enough patients with a specific disease or condition to conduct a study or determine whether you would be a good candidate for a study that will involve interaction with you. In this situation,
they may contact you to ask you if would like to participate in a study.
Health or Safety. We may use or disclose your health information to prevent or lessen a serious and imminent threat to the health or safety of a person or the general public.
Specialized Government Functions. We may use and disclose your health information for authorized national security activities or to units of the government with special functions, such as the U.S. military or the
U.S. Department of State under certain circumstances.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official
for certain purposes. For example, we may disclose your health information to a correctional institution to provide you with health care.
We may disclose your health information to the extent necessary to comply with workers’ compensation law or similar laws.
To Comply With the Law. We may use and disclose your health information when required to do so by any other law not already referred to in this section.
V. Your Rights Regarding Your Health Information
Right to Request Restrictions on Certain Uses and Disclosures of Your Health Information. You may ask for restrictions on how your health information is used or to whom your health information is disclosed:
(1) for treatment, payment and health care operations, (2) to family or friends involved in your care or payment of medical bills, or (3) to authorities involved in disaster relief efforts. While we will consider all
requests for restrictions, we are not required to agree to your request. To request restrictions on how we use and disclose your health information for the purposes described above, you must obtain a restriction
request form from our Health Information Management staff and submit the completed form to them. We will send you a written response.
Right To Request Restrictions on Disclosure of Your Health Information to a Health Plan. You have a right to request, in writing, restrictions on disclosure of your health information to a health plan if the
information pertains solely to a health care item or service for which you, or someone on your behalf, has paid out-of-pocket, in full.
Right to Receive Confidential Communications of Your Health Information. We will accommodate any reasonable request that we communicate your health information in different ways or places. For example, you
may wish to receive your billing statement at a P.O. Box instead of a street address. We may ask you to put your request in writing.
Right to Cancel Authorization to Use or Disclose Your Health Information. You may cancel an authorization you have provided to us except if we have already relied on it. To cancel an authorization, you must
obtain a cancellation form from our Health Information Management staff and submit the completed form to them.
Right to Inspect and Copy Your Health Information. You may request access to your health information in order to review or request copies of such information. In certain situations, we may deny you
access to a portion of your health information (for example, mental health records or information gathered for judicial proceedings) as allowed by law. To review or obtain copies of your health information, you must
obtain an access request form from our Health Information Management staff and submit the completed form to them. We will charge you a reasonable fee for copies of your health information, which may include the cost
of copying (including cost of supplies and labor), postage and preparing an explanation or summary of your health information. You have the right to request that the copy be provided in an electronic form or format.
If the form and format are not readily producible, we will work with you to create a reasonable electronic form or format. If you decline the available electronic formats, we will provide you with a paper copy.
You should note that, if you are a parent or legal guardian of a minor (child under age 18), certain portions of the minor’s health information may not be accessible to you (for example, records relating to alcohol
and other drug abuse treatment, HIV test results, or if the minor is emancipated).
Right to Request to Correct Your Health Information. You may ask us to correct your health information. While we will consider all requests for corrections, we may deny your request for legitimate
reasons (for example, if your health information is accurate and complete or we did not create the health information you believe is incorrect). To request a correction to your health information, you must obtain
an amendment request form from our Health Information Management staff and submit the completed form to them. The completed form must include the reason for your request.
Right to Receive a Record of Disclosures of Your Health Information. You may ask for a list of certain disclosures of your health information made by us, in the six years prior to the date of your request.
This list must include the date of each disclosure, who received the health information disclosed, a brief description of the health information disclosed, and why the disclosure was made. This list will not include
disclosures made to you, or for purposes of treatment, payment, health care operations, or for certain other purposes. To request a list of such disclosures, you must obtain an accounting request form from our Health
Information Management staff and submit the completed form to them. If you request a list of such disclosures more than once during a twelve (12) month period, we may charge you a reasonable fee.
Right to Receive Paper Copy of This Notice.You may request a paper copy of this Notice at any time, even if you earlier agreed to receive this notice electronically. You may also access this Notice on our
website at www.marshfieldclinic.org.
Right to Your Own Billing Account. If you share a multiple adult account (that is, an account with two or more adults where the adults receive the bill for all individuals in this account), you have the right
to request your own account. If you want to remain in the multiple-adult account, you will need to sign an authorization form to allow the disclosure of your health information on the bill to other adults in your
account. If you want your own account, you may ask our Customer Service staff in Patient Financial Services to create this account. The establishment of a new account for you, separate from that of your spouse and
children, means that you may receive multiple bills and will need to write separate checks for each bill. If you have questions regarding these options, call 1-800-782-8581 and ask for Customer Service.
Right to Notification of Breach. You have the right to be informed of a breach of your protected health information. We will notify you, within 60 days of discovery, if we breach your unsecured protected
If you believe your privacy rights have been violated, you may file a complaint with the federal Department of Health and Human Services and us. We will not retaliate against you for filing such a complaint.
To file a complaint, please contact our Nurse Liaisons, Marshfield Clinic, 1000 N. Oak Ave., Marshfield, WI 54449. All complaints must be submitted in writing.
If you have any questions about your privacy rights or the information in this Notice, you may contact our Nurse Liaisons at 1-800-782-8581.