Watertown Area Health Services (WAHS) provides health care to our patients, residents, and clients in partnership with physicians and other professionals and organizations. This notice applies to the privacy practices of the participants in our Organized Health Care Arrangement, which includes by all facilities, departments and units of Watertown Area Health Services and the health care professionals who treat you at our locations, including all physicians and allied health practitioners on our medical staff. Your medical information will be shared with these professionals as necessary to carry out treatment, payment, and health care operations relating to our Organized Health Care Arrangement. Mental health treatment records or HIV test results may not be shared for these purposes without your written permission except as set forth below.

Our pledge to you:

We understand that medical information about you is personal. We are committed to protecting medical information about you. This notice applies to all of the records of your care that we maintain, whether created by facility staff 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 your doctor's office. We are required by law to:

o Keep medical information about you private.
o Give you this notice of our legal duties and privacy practices with respect to medical information about you.
o Follow the terms of the notice that is currently in effect.

Changes to this Notice.

We may change our privacy policies and this notice at any time. Changes will apply to medical information that we already hold, as well as new information that we obtain after the change occurs. Before we make a significant change in our privacy policies, we will change our notice, make the new notice available to our patients and others upon request, and post the new notice at each of our service delivery sites and on our web site at www.watertownmemorialhospital.com.

How we may use and disclose medical information about you.

o We may use and disclose medical information about you for treatment (such as sending medical information about you to a specialist as part of a referral); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support certain of our health care operations (such as comparing patient data to improve treatment methods). We may need your written permission to disclose information taken from your mental health treatment records or HIV test results for payment purposes, or to disclose medical information or your mental health treatment records or HIV test results for certain health care operations.

o We may use and disclose medical information about you without your prior authorization for other purposes:

o We may want to use your health information for appointment reminders, and to communicate with you about treatment alternatives and other health-related benefits and services that may be of interest to you.
o We may want to use information found in your medical record, such as your name, address and phone number, to contact you for our fund-raising purposes. We will explain how you may opt out of receiving future fundraising communications from us with any fundraising materials we may give to you.
o We may also contact you to complete patient satisfaction surveys to better our programs and services we offer. You may also receive cards of kindness. You may also receive post-treatment and follow-up telephone calls.
o Watertown Area Health Services Facility Directory. Unless you object, we may use your name, location in our facility, and your religious affiliation for our directory. This information may be disclosed to members of the clergy, and (except your religious affiliation) to people who ask for you by name. If you are not present or are incapacitated or it is an emergency, we will use our professional judgment and any prior preference you may have expressed, to determine if listing your information in our facility directories is in your best interest. If we list your information, we will ask whether you object to continuing the listing as soon as you become available. We may not disclose your general medical condition or any information taken from mental health treatment records or HIV test results in our facility directories without your written permission.
o To those involved with your care or payment of your care. , Unless you object, we may release your name and location in our facility to family members, relatives, or close personal friends are helping care for you or helping you pay your medical bills. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing your name and location is in your best interest under the circumstances.

In addition, we may release this information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location. We may allow you to agree or disagree orally to such release, unless there is an emergency.

Release of any additional medical information to persons involved in your care or payment for care can be made only with your written permission.

o We may use and disclose your medical information without your permission when required by law, and when authorized by law for the following kinds of public health and interest activities, judicial and administrative proceedings, law enforcement, research, and other public benefit functions:

o For public health, including to report disease and vital statistics, to report to registries, child abuse, and adult abuse or neglect;
o To avert a serious and imminent threat to health or safety;
o For health care oversight, such as activities of state licensing and peer review authorities, and fraud prevention enforcement agencies;
o For research;
o In response to court and certain administrative orders and other lawful process;
o To law enforcement officials with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons;
o To coroners, medical examiners, and (with respect to HIV test results) funeral directors;
o To organ procurement organizations by a Watertown Memorial Hospital;
o To the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
o As authorized by state worker's compensation laws.

We may not disclose HIV test results, certain confidential medical information or mental health treatment records for certain of the purposes listed above without your written permission, unless required by law. Your HIV test results, if any, may be disclosed as set forth in Wisconsin Statutes § 252.15(5)(a). A listing of the persons or circumstances set forth in that statute is available on request.

Other uses of medical information.

In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect.

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 Privacy Office listed at the bottom of this notice. Specifically, you have the right to:

o Inspect and copy 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 psychotherapy notes or information gathered for judicial proceedings, for example. In addition, we may charge you a reasonable fee if you want a copy of your health information.

o Request to correct your health information. If you believe your health information is incorrect, you may ask us to correct the information. You may be asked to make such requests in writing and to give a reason as to why your health information should be changed. However, if we did not create the health information that you believe is incorrect, or if we disagree with you and believe your health information is correct, we may deny your request. You may appeal, in writing, a decision by us not to amend a record.

o Request restrictions on certain uses and disclosures. You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify. However, we are not required to agree to your requested restriction. If we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law, and we may terminate our agreement at any time.

If you receive certain medical devices (for example, life-supporting devices 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. You also may be able to opt out of use or disclosure of your medical information to government agencies or for research purposes, unless the disclosure is required by law.

o 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 special, private room or through a written letter sent to a private address. We must accommodate reasonable requests that specify the alternative means or location for confidential communication, and explain how payment for our services will be handled. We will not ask you to explain the reason for your request.

o Receive a record of disclosures of your health information. You have the right to receive a list of disclosures of your health information we have made during the previous six years for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities. The list will not include disclosures before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to your additional requests. This list must include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. You also have the right to a list of all written disclosures of your mental health treatment records.

o Obtain a paper copy of this notice. Upon your request, you may at any time receive a paper copy of our current notice, even if you earlier agreed to receive this notice electronically. This notice is available on our website at www.watertownmemorialhospital.com.

o Complain. If you believe your privacy rights have been violated, you may file a complaint with us and with the federal Department of Health and Human Services. We will not retaliate against you for filing such a complaint. To file a complaint with either entity, please contact our Privacy Office at (920) 262-4279, who will provide you with the necessary assistance and paperwork.

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact the Privacy Office at (920) 262-4279.

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

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

By signing this form, you acknowledge that Watertown Area Health Services (WAHS) has given you a copy of its Privacy Notice, which explains how your health information will be handled in various situations. We must try to have you sign this form on your first date of service with us after April 14, 2003. This includes the situation where your first date of service occurred electronically.

If your first date of service with us was due to an emergency, we must try to give you this notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency.

Check all that are true:

[ ] I have received Watertown Area Health Services Privacy Notice.

[ ] Watertown Area Health Services has given me the chance to discuss my concerns and questions about the privacy of my health information.

__________________________________________________________
Patient's Signature

__________________________________________________________
Legal Representative/Parent/Guardian

Watertown Area Health Services staff should complete if Acknowledgement Form is not signed:

1. Does patient have a copy of the Privacy Notice?

[ ] Yes [ ] No

2. Please explain why the patient was unable to sign an acknowledgement form
and Watertown Area Health Services efforts in trying to obtain the patient's signature:
___________________________