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For the purposes of this Notice, Monroe Clinic and the Madison Radiologists, S.C. are participating in a joint arrangement. Both will continue to maintain separate businesses, however, this joint arrangement means that the terms outlined in this Notice apply to both organizations named and that these organizations may share patient information as necessary to provide our patients with treatment, obtain payment for services, and conduct our healthcare operations. Wherever Monroe Clinic is named in this document, please acknowledge that it means Monroe Clinic and the Madison Radiologists, S.C.

Monroe Clinic is dedicated to maintaining the privacy of your health information. You are being given this notice as a description of our legal duties and privacy practices concerning your personal health information. In general, whenever we need to release your health information, we must only release specific, limited information to achieve the purpose for which the information is being used or disclosed. According to Federal law, State statutes, and as healthcare professionals, Monroe Clinic must follow the privacy practices described in this notice.

We reserve the right to change the privacy practices described in this notice in accordance with the law. Changes to our privacy practices would apply to all health information that we maintain. If we change our privacy practices, you will be provided with a revised copy of the privacy notice at the time of your first visit to Monroe Clinic after the revision has been made.

Once you have received this privacy notice or we have made a good faith effort to provide you with this notice, we can use your health information for the following purposes:

  1. TREATMENT. Your doctor may use your health information to provide care to you and disclose your health information to others who provide care to you. For example, a doctor may use the information in your medical record to determine which treatment option, such as a drug or surgery, best meets your health needs. The treatment selected will be documented in your medical record so that other healthcare professionals can make informed decisions about your care. If it is determined that a prescription is needed to provide you with the best treatment, your information will be used to write the prescription and your information will be disclosed to a pharmacy when the prescription is ordered for you. Nursing or other healthcare professionals (example: technicians and therapists) may use the information to verify your doctor's treatment orders. You should also be aware that not all laboratory tests can be performed in Monroe Clinic laboratory facilities. We may send your lab samples to an outside laboratory to perform the test and send the results back to Monroe Clinic.

  2. PAYMENT. 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 pass such health information on to your insurance company in order to help receive payment for your medical bills. We also may use and disclose your information to obtain payment from other third parties that may be responsible for payment of your healthcare costs, such as other family members. We may also use your information to bill you directly for services and items. Monroe Clinic may also need to obtain prior approval from your insurance company and may need to give the insurance company information that will explain the necessity of the care and services that will be provided to you.

  3. HEALTH CARE OPERATIONS. Monroe Clinic may need to use or disclose information for the purposes of operating our business. We may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care we deliver. These quality and cost improvement activities may include evaluating the performance of your doctors, nurses, and other healthcare professionals, or for examining the effectiveness of the treatment provided to you when compared to patients in similar situations. We may need to use your information to provide data for auditing, compliance programs, and legal services. Information may also be used to assist us in creating supervised learning programs for students and trainees of healthcare professions.

Additionally, we may want to use your health information as a way to contact you. For example, we may want to send you a reminder about an appointment. In this case, we would use the computer system to determine the date and time of your next appointment, and obtain your address. We would use that information to send you a note to help you remember the appointment.

Or, we may look at your medical information and decide that another treatment or new service we offer may interest you. For example, if you are a diabetic patient, we may send you information on new diabetes treatment options, the Diabetic Support Group, or the Diabetes Clinic.

Without Your Consent or Authorization

According to Federal regulations and state laws, we may use your health information without specific authorization from you for the following purposes:

  1. As required or permitted by law. We will disclose your health information when required to do so by any Federal, State, or local law. Sometimes we must report some of your health information to legal authorities such as law enforcement officials, court officials, or government agencies. We will notify the appropriate authorities if we believe a patient is a victim of abuse, neglect, or domestic violence. We may disclose health information to law enforcement under certain circumstances. For instance, under limited circumstances if you are the victim of a crime or for the purposes of reporting a crime. We may also need to report certain types of wounds or physical injuries as required by law, or in response to a court order, warrant, or other authorized legal proceeding.

  2. For public health activities. We may be required to report your health information to authorities to help prevent or control disease, injury, or disability. This may include using your medical record to report certain diseases, injuries, birth or death information, or information of concern to the Food and Drug Administration. We may use or disclose your information to notify an appropriate individual when there has been exposure to a communicable disease or there may be a risk for contracting or spreading a disease. We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety.

  3. For health oversight activities. We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline, or license those who work in the health care system or for government benefit programs.

  4. For activities related to death. We may disclose your health information to coroners, medical examiners and funeral directors so they can carry out their duties related to your death, such as identifying the body, determining cause of death, or in the case of funeral directors, to carry out funeral preparation activities. We may also use or disclose your health information to the appropriate authorities if we have reason to believe that your death was the result of criminal conduct.

  5. For organ, eye, or tissue donation. We may disclose your health information to people involved with obtaining, storing, or transplanting organs, eyes, or tissue for donation and transplant purposes.

  6. For research. Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research. Such research might try to find out whether a certain treatment is effective in curing an illness.

  7. To avoid a serious threat to health or safety. As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your health or safety or the health and safety of the public.

  8. For military, national security, or incarceration/law enforcement custody. If you are involved with military, national security, or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may release your health information to the proper authorities so they may carry out their duties under the law. We may use health information to assist in identifying or locating a suspect, fugitive, missing person, or material witness.

  9. For workers' compensation. We may disclose your health information to the appropriate persons in order to comply with the laws related to workers' compensation or other similar programs. These programs may provide benefits for work-related injuries or illness. We will only disclose information related to the workers' compensation claim.

  10. To those involved with your care or payment of your care. Upon admission to the hospital, you will be asked to identify a "spokesperson". This is the only person to whom we will release information regarding your care and condition. If you are unable to identify a spokesperson at the time of admission due to your condition, we will use information from a previous admission or our reasonable and best medical judgment. If any other person inquires about your medical condition or care, that person will be referred to your designated spokesperson. In the outpatient setting, information will be shared with the individual(s) that accompany you into the patient room. If you do not wish for your information to be shared with the other individual(s) who have accompanied you, let your physician and/ or nurse know that you wish to receive your health information in private. Your healthcare and condition information will not be released to any other individual without your written permission. Regarding payment for care, we will give information to you and to the person indicated as the responsible party for your bill. In the event that a power of attorney for healthcare is indicated and effective information for payment will be shared with that individual. Information regarding payment will be shared with individuals other than yourself, the responsible party, or the power of attorney for healthcare only with your written permission. In addition, we may release your health information to organizations authorized to handle disaster relief efforts (example: The Red Cross) so those who care for you can receive information about your location or health status. We may also release information in the case of a disaster situation to those who may need to know in order to prevent further public harm.

  11. Monroe Clinic Directory. You will be asked at the time of an admission whether you wish others to be able to contact you while in the hospital. If you wish, information will be released to your visitors regarding your location in the facility and your telephone extension number. If you prefer that you not have visitors or phone calls, you may say so at this time. Religious affiliation will also be made available and disclosed only to clergy. If you do not wish to have your religious affiliation known and do not wish to have visits from the clergy, you may designate so at the time of admission. If you are unable to designate your wishes at the time of your admission, we will refer to the information you gave us during a previous admission or use our best and reasonable medical judgment.

NOTE: Except for the situations listed above, we must obtain your specific written authorization/ informed consent for any other release of your health information. If you sign an authorization/ informed consent to release information, you may withdraw your authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization, please contact and submit your written withdrawal to Monroe Clinic Medical Records Department.

Your Health Information Rights

You have several rights with regard to your health information. If you wish to exercise any of the following rights, please contact the Medical Records Department. Specifically, you have the right to:

  1. Inspect and obtain a copy of your health information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. However, this right does not apply to information gathered for judicial proceedings. In addition, we may charge you a reasonable fee if you want a copy of your health information. If you want to inspect or obtain a copy of your health information, you must complete and submit Monroe Clinic's Authorization For Disclosure of Medical Records form to the Medical Records department. Please be aware that records are not always immediately available for copy or inspection. Please allow at least 48 hours from the date of service to obtain access for copies or inspection. Inspection may occur during regular business hours.

  2. Request to correct your health information. If you believe your health information is incorrect, you may ask us to correct the information. You will be asked to make the request in writing and give a reason as to why your health information should be changed. Any corrections accepted by Monroe Clinic will be appended to the original documentation. Whenever the original documentation is used or disclosed, the new corrective statement will accompany the documentation. The original statements will not be completely removed from your record. For your convenience, a form for making this request may be obtained, at no charge to you, from Monroe Clinic. All requests for correction must be submitted to Monroe Clinic's Medical Records department. Your request will be denied if you do not submit the request in writing. Your request may also be denied if (1.) we determine the original information to be accurate and complete, (2.) the information is not part of the information kept by or for Monroe Clinic, (3.) the information was not created by Monroe Clinic, unless the individual or entity that created the information is not available to amend the information, or (4) the information is restricted by a state or federal law.

  3. Request restrictions on certain uses and disclosures. You have the right to ask for restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment, or our payment, or health care operation activities. For example, if you receive certain medical devices such as those used outside our facility, you may refuse to release your name, address, telephone number, social security number, or other identifying information for purpose of tracking the medical device. If you request restriction on information that would prohibit collection of payment from a third party (example: insurance company), you will be responsible for the payment for that service. In order to request a restriction, you must submit the request in writing. The restriction must be stated in a clear, concise manner and must include the following: (a.) the information you wish restricted, (b.) whether you are limiting Monroe Clinic's use or disclosure, or both, and (c) to whom you want the limits to apply. For your convenience, and at no charge to you, there is a form available from Monroe Clinic to assist you with providing the necessary information. The use of our form is not required, but would be helpful in filing your request. Please note that we are not required to agree in all circumstances to your requested restriction and will notify you in writing if we cannot agree. If we do agree to your request, we are bound by our agreement except when otherwise required by law or in emergencies.

  4. As applicable, receive confidential communication of health information. You have the right to ask that we communicate your health information to you in different ways or places. For example, you may wish to receive information about your health status in a more private room or through a written letter sent to a private address. Your request for confidential communication must be made in writing if at all possible. For your convenience, a form may be obtained from Monroe Clinic, at no charge to you, to assist you in making your request. We must accommodate reasonable requests. If the request is deemed unreasonable or is impossible for Monroe Clinic to comply with, we will notify you.

  5. Receive a record of disclosures of your health information. You have the right to ask for a list of the disclosures of your health information we have made during the previous six years, but the request may not include dates before April 14, 2003. This list must include the date of each disclosure, who received the disclosed health information, a brief description of the information disclosed, and why the disclosure was made. Certain routine disclosures will not be included on this list, such as a doctor sharing information with his or her nurse for purposes of your treatment, or when the billing department files an insurance claim. Your request to receive this information must be made in writing. For your convenience, a form for this purpose may be obtained from Monroe Clinic, at no charge to you. The first list you request within a 12 month period is free of charge, but Monroe Clinic may charge you for additional lists within the same 12 month period. You will be notified of any costs involved with additional requests, and you may withdraw your request before you incur any costs. We must comply with your request for a list within 60 days, unless you agree to a 30 day extension.

  6. Obtain a paper copy of this notice. Upon your request, you may at any time receive a paper copy of this notice, even if you previously reviewed this notice on our website. You may also at any time request additional paper copies if you misplace your original copy.

  7. Complaints. If you believe your privacy rights have been violated, you may file a complaint with us and /or with the Federal Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing such a complaint. To file a complaint with either Monroe Clinic or the Office for Civil Rights, please contact Monroe Clinic's Patient Advocate at (608) 324.1400. You will be provided with the necessary assistance.

    If you have any questions regarding your privacy rights or the information in this notice, please contact Monroe Clinic's HIPAA Coordinator at (608) 324-1802.

    This Notice of Medical Information Privacy is Effective April 14, 2003.

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