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Privacy Notice

Agnesian HealthCare is an organized healthcare arrangement including the following: Agnesian HealthCare Enterprises, Consultants Laboratory, Fond du Lac Regional Clinic, Ripon Medical Center, St. Agnes Hospital, St. Francis Home and Waupun Memorial Hospital. Agnesian HealthCare is required by law to maintain the privacy of your personal health information and to provide you with this notice describing Agnesian HealthCare's legal duties and privacy practices concerning your personal health information.

Without Your Written Consent or Authorization

Agnesian HealthCare can use your health information for the following purposes:

  1. As required or permitted by law. In certain circumstances, Agnesian HealthCare may have to report some of your health information to legal entities, such as law enforcement officials, court officials or government agencies. Examples of such circumstances may be to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
  2. For public health activities. Agnesian HealthCare 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, information related to the jurisdiction of the Food and Drug Administration, or information related to child abuse or neglect. Agnesian HealthCare may also have to report certain work-related illnesses and injuries to your employer so that workplace medical surveillance activities can be conducted.
  3. For health oversight activities. Agnesian HealthCare may disclose your health information to authorities for audit, investigation, inspection, licensure, disciplinary or other purposes related to oversight of the healthcare system or government benefit programs.
  4. For activities related to death. Agnesian HealthCare 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 the cause of death, or in the case of funeral directors, to carry out funeral preparation activities.
  5. For organ, eye or tissue donation. Agnesian HealthCare may disclose your health information to entities involved in obtaining, banking or transplanting organs, eyes or tissue of cadavers for donation or transplantation purposes.
  6. For research. Under certain circumstances, and only after a special approval process, Agnesian HealthCare may use and disclose your health information to help conduct research. Such research might involve studies related to evaluating the effectiveness of a treatment.
  7. To avoid a serious threat to health or safety. As required by law and standards of ethical conduct, Agnesian HealthCare may use or disclose your health information to the necessary authorities if Agnesian HealthCare believes, in good faith, that such use or disclosure is necessary to prevent or minimize a serious and imminent threat to your or the public's health or safety.
  8. For military, national security, or incarceration/law enforcement custody. If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, Agnesian HealthCare may disclose your health information to the proper authorities so they may carry out their duties under the law.
  9. For workers' compensation. Agnesian HealthCare 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 illnesses.
  10. Agnesian HealthCare directory. Unless you object, Agnesian HealthCare may use your health information, such as your name, location in which Agnesian HealthCare facility, your general health condition (e.g., "fair," "good," "serious," "critical," or "treated and released"), and your religious affiliation for an Agnesian HealthCare directory. The information about you contained in the Agnesian HealthCare directory will be disclosed to people or media representatives who ask for you by name. However, the information about your religious affiliation will only be disclosed to clergy. Agnesian HealthCare may allow you to object or agree orally regarding the use of your health information for directory purposes.
  11. To those involved with your care or payment of your care. If people such as family members, relatives, or close personal friends are helping care for you or helping you pay your medical bills, Agnesian HealthCare may disclose health information about you to those people. The information disclosed to these people may include your location within which Agnesian HealthCare facility, your general condition, or death. You have the right to object to such disclosure, unless you are incapacitated or there is an emergency. In addition, Agnesian HealthCare 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. Agnesian HealthCare may allow you to object or agree orally to such disclosure, unless there is an emergency.

NOTE: Except for the situations listed above, any other use or disclosure of your health information requires Agnesian HealthCare to obtain your written authorization. You may withdraw your authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to the medical records department of the appropriate covered entity of Agnesian HealthCare.

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 of the appropriate covered entity of Agnesian HealthCare.

Specifically, you have the right to:

  1. Request restrictions on certain uses and disclosures. You have the right to notify Agnesian HealthCare that you want restrictions placed on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or Agnesian HealthCare's payment or healthcare operation activities. Or, you may want to restrict the health information provided to family or friends involved in your care or payment of medical bills. You may also want to restrict the health information provided to authorities involved with disaster relief efforts. However, it should be noted that Agnesian HealthCare is not required to agree in all circumstances to your requested restriction. If you receive certain medical devices (for example, life-supporting devices used outside Agnesian HealthCare's 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.
  2. As applicable, receive confidential communication of health information. You have the right to request alternative means or locations when Agnesian HealthCare communicates your health information to you. Agnesian HealthCare must accommodate reasonable requests.
  3. To 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 compiled for judicial proceedings, for example. In addition, Agnesian HealthCare may charge you a reasonable fee if you want a copy of your health information.
  4. To amend your health information. If you believe your health information is incorrect, you may ask Agnesian HealthCare to amend the information. You will be asked to make such requests in writing and to give a reason as to why your health information should be changed. However, if Agnesian HealthCare did not create the health information that you believe is incorrect, or if Agnesian HealthCare disagrees with you and does believe your health information is correct, Agnesian HealthCare may deny your request.
  5. To receive an accounting of disclosures of your health information. In some limited instances, you have the right to request an accounting of the disclosures of your health information Agnesian HealthCare has made during the previous six years, but the request cannot include dates before April 14, 2003. This accounting 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. Agnesian HealthCare must comply with your request for an accounting within 60 days, unless you agree to a 30 day extension, and Agnesian HealthCare may not charge you for the accounting, unless you request such accounting more than once per year. In addition, Agnesian HealthCare will not include in the accounting disclosures made to you, or for purposes of treatment, payment, healthcare operations, the Agnesian HealthCare directory, national security, law enforcement/corrections, and certain health oversight activities.
  6. To 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 earlier agreed to receive this notice electronically. You can print an electronic copy by accessing the Agnesian HealthCare website.
  7. To complain. If you believe your privacy rights have been violated, you may file a complaint with Agnesian HealthCare and with the federal Department of Health and Human Services (Office of Civil Rights). Agnesian HealthCare will not retaliate against you for filing such a complaint.
  8. To file a complaint with any Agnesian HealthCare entity or if you have questions or concerns regarding your privacy rights or the information in this notice, please contact the appropriate person below:

Contact Us

Agnesian HealthCare Privacy Officers:
  • Consultants Laboratory (920) 926-5871
  • Fond du Lac Regional Clinic (920) 926-8347
  • Ripon Medical Center (920) 926-8347
  • St. Agnes Hospital (920) 926-8347
  • St. Francis Home (920) 923-7980
  • Waupun Memorial Hospital (920) 926-8347
  • Agnesian HealthCare Enterprises (920) 926-6010

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