Notice of Privacy Practices
This Notice of Privacy Practices is available in Spanish and Hmong. To receive a copy, contact the Privacy Officer at (608) 775-3549.
Este aviso de su informacion confidencial y privada esta disponible en Espanol y Hmong. Para recibir una copia, comuniquese con el Oficial privado al (608) 775-3549.
Tsab ntawv ntawm Kev Txwv tsis pub leej twg paub no mauj sau ua ntawv Spanish thiab ntawv Hmoob. Yog xav tau ib tsab, thov hu rau Privacy Officer ntawm (608) 775-3549.
PLEASE RETURN THE ACKNOWLEDGMENT OF RECEIPT AVAILABLE IN PDF FORMAT. Mail a completed Acknowledgement to:
Gundersen Health System
1900 South Ave., CBO-002
La Crosse, WI 54601-5400
View a letter regarding our privacy practices from Gundersen CEO, Scott Rathgaber, MD.
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
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.
When it comes to your protected health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- We will provide a copy or a summary of your protected health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain protected health information for treatment, payment, or our operations. We are not required to agree to your request.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared information
- You can ask for a list (accounting) of the times we've shared your protected health information, who we shared it with, and why for six years prior to the date you ask.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your protected health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 2.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling (877) 696-6775.
- We will not retaliate against you for filing a complaint.
For certain protected health information, you can tell us your choices about what we share. If you have a clear preference for how we share your protected health information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
- Share protected health information with your family, close friends, or others involved in your care
- Share protected health information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information, to the extent permitted by law.
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to contact you again. To opt-out of fundraising, contact the Foundation by calling (800) 362-9567, ext. 56600 or email the Foundation at: email@example.com.
In these cases, we never share your protected health information unless you give us written permission:
- Most marketing purposes
- Sale of your information
Our Uses and Disclosures
How do we typically use or share your protected health information?
We typically use or share your health information in the following ways:
We may use your protected health information to provide you with medical treatment or services and, to the extent permitted by applicable law, share it with other professionals who are treating you. Example: A provider treating you for an injury asks another provider about your overall health condition.
Run our organization
We can use and share your protected health information to run our organization, improve your care, contact you when necessary and to train our staff and students. Example: We use protected health information about you for certain administrative, financial, legal, quality assessment and improvement, accreditation, credentialing and training activities.
Payment for your services
We can use and share your protected health information to bill and obtain payment from health plans or other entities. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity; and undertaking utilization review activities.
We may share your protected health information with third parties that do activities for Gundersen Health System.
How else can we use or share your health information?
We are allowed or required to share your protected health information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your protected health information for these purposes.
Help with public health and safety issues
We can share protected health information about you for certain situations such as:
- Preventing or controlling disease and managing epidemics
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting of events that we are required or permitted to report
- Preventing or reducing a serious threat to anyone's health or safety
Under certain circumstances, we can use or share your protected health information for clinical or medical research.
Comply with the law
We will share protected health information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.
Respond to organ and tissue donation requests
We can share protected health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share protected health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
We can use or share protected health information about you:
- For workers' compensation claims
- For specific instances, we may share with law enforcement officials
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Health information availability after death
We may use or disclose protected health information without your authorization 50 years after the date of your death.
Respond to lawsuits and legal actions
We can share protected health information about you in response to a court or administrative order, discovery request or in response to a subpoena.
We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Gundersen Health System's contact person for issues regarding patient privacy and the Privacy Rule is: Privacy Officer, 1900 South Avenue, AVS-001, La Crosse, Wisconsin 54601, Privacy Office at (608)775-7439, PrivacyOffice@gundersenhealth.org.
Other Instructions for Notice
- Effective Date of this Notice: September 15, 2020
- We will only share any substance abuse treatment records without your written permission when required or permitted by law.
- Gundersen Health System participates in the About Health Organized Health Care Arrangement (OHCA), an organized system of health care in which more than one covered entity participates in the joint arrangement. The purpose of the participation includes conducting quality assessment and improvement activities, conducting utilization review, and performing other clinically integrated network activities. Your health information may be shared with other About Health OHCA participants for these purposes.
- We electronically exchange health care information to facilitate access to health and/or mental 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, health information exchange will allow us to make your medical information available to those who need it to treat you at the hospital. Access to your health and/or mental health information is readily available, when needed, which means better care for you. You have the right to opt-out of the health information exchange by contacting our Privacy Office.