Notice of Privacy Practices

St. Croix Regional Medical Center’s Notice of Privacy Practices

We understand that medical information about you and your health is personal.  We are committed to protecting medical information about you. We create a record of care and services you receive in our facility.  We need this record to provide you with quality and to comply with certain legal requirements.  This notice applies to all of the records of your care that we maintain.  

This notice describes the ways in which we may use and disclose information about your health to carry out treatment, payment and health care operations, and for other purposes as permitted or required by law.  It also describes your rights and our duties regarding the use and disclosure of your health information.  


The following categories describe different ways that we may use and disclose information about your health without your written authorization.  For each category of uses or disclosures we will explain what we mean and try to give you some examples; however, not every use or disclosure in a category will be listed.

Treatment: We may use and disclose medical information about you to provide, coordinate or manage your health care and any related service.  We may disclose medical information about you to doctors, nurses, technicians, medical students or other medical center personnel who are involved in taking care of you at the medical center.  We may also disclose medical information about you to people outside of the medical center who may be involved in your medical care after you leave the medical center, such as physician specialists, family members, home health agencies, or others we use to provide services that are part of your care.

Payment: We may use and disclose medical information about you so that the treatment and services you receive at the medical center may be billed to payment may be collected from you, an insurance company or a third party.  We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Operations: We may use and disclose medical information about you for medical center operations.  These uses and disclosures are necessary to make sure that all of our patients receive quality care and enable us to run our business.

Information Provided to You: We may use and disclose your health information to assist us in communicating with you about appointment reminders, test results, and treatment information.  We may contact you by telephone or mail to provide you with this information.

Marketing: We may use your health information to give you information about other treatments or health-related benefits and services that we provide and that may be of interest to you. If you do not wish St. Croix Regional Medical Center to use your information for marketing purpose, you may notify the Privacy Officer.
Uses and disclosures of your protected medical information for marketing purposes will require your authorization in those instances when the medical center receives direct or indirect payment from a third party whose product is being marketed, or giving or selling protected patient information to a third party for marketing purposes.

Fundraising Activities: We may use your demographic (name and address) health information or share it with our foundation to contract you regarding our fundraising activities. If you do not wish St. Croix Regional Medical Center to use your information for fundraising purposes, you may notify the Privacy Officer.

Hospital Directory: Unless you object, we may include certain limited information about you in the hospital directory while you are a patient in the hospital.  This allows us to tell family, friends or clergy that you are a patient and what room you are in.  This information may include your name, location in the hospital, your general condition in simple terms (fair, stable, so forth) and your religious affiliation (for clergy only).

Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care.  We may also give information to someone who helps pay for your care.  We may also tell your family or friends your condition and that you are in the hospital.  You have the right to object to such disclosure, unless you are unable to function or there is an emergency.  In addition, we may disclose medical information about you to organizations authorized to handle disaster relief efforts so your family or those who care for you can be notified about your condition, status and location.

Research: Under circumstances, we may use and disclose minimally necessary information about you for research purposes.  All research projects, however, are subject to a special approval process.  Before we use or disclose medical information for research, you must sign a research authorization form.

As Required by Law: We may disclose your health information when required to do so by federal, state or local law.

Public Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others or the general public.

Organ Donation: We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child or elder abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration (FDA) problems with products and reactions to medications; and reporting disease or infection exposure.

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections and licensure.

Health Information Exchanges: We may participate in health information exchanges, record locator services and other similar activities designed to enable us and other providers to give you safer and more efficient care.  We will get your permission to share your personal information for these purposes if required by law.

Legal Process: We may disclose medical information about you in response to a state or federal court order, legal orders, subpoenas or other legal documents.

Deceased Person Information: We may disclose your health information to coroners, medical examiners or funeral directors as necessary to carry out their duties.

Military, National Security or Incarceration/Law Enforcement Officials: If you are involved with the military, law enforcement officials, national security or intelligence activities or you are in custody of law enforcement officials, or an inmate of a correctional institution, we may release your medical information to the proper authorities so they may carry out their duties under the law.


Psychotherapy Notes: Most uses and disclosures of psychotherapy notes (the private notes of a mental health professional kept separately from the record) will require your authorization to disclose.

•Sale of Protected Health Information: The sale of your protected health information is prohibited without your authorization with several exceptions for public health, research (with limitations), treatment and payment, corporate transactions, business associate services, to you personally, and as required or permitted by law (with limitations).

Other uses and disclosures of information about your health that are not described in this notice or are not otherwise permitted by law will be made only with your written authorization.  You may revoke such authorization as described in this notice.


You have the following rights regarding the medical information we maintain about you, which you may exercise by submitting your request in writing to:

Attention: Health Information Services
St. Croix Regional Medical Center
235 State Street
St. Croix Falls, WI 54024

Right to Inspect and Copy: You have the right to inspect and to receive a copy of your medical record, billing record and other records used to make decisions about your care.  To inspect and receive a copy of these records, you must submit your request in writing to the Health Information Services Department of the medical center.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.  If the information requested is maintained in an electronic health record, you may request a copy of your personal information in an electronic format.  To the extent possible, we will provide access in the format requested.  If we deny your request to inspect and receive a copy of your medical information, you may submit a written request for a review of that decision.

Right to Restrict Disclosure to Health Plans: You have the right to prohibit us from disclosing to your health plan personal information related to a particular service if you pay us for that service up front and in full.

Right to Amend: If you feel the medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment as long as the information is kept by or for the medical center.  We will consider your request, but we are not required to agree with your changes.

Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosers”.  This is a list of the disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request n writing to the Health Information Services Department of the medical center.  Your request must state a time period which may not be longer than six years and may not include dates before March 1, 2003.  The first list you request will be provided free.  For additional lists you request within a 12-month period, we may charge you a fee for the costs of providing the lists.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you may ask that we only contact you at work or by mail.  We will make every effort to accommodate all reasonable requests.

Right to a Copy of This Notice: You have the right to a paper copy of this notice.  You may ask us to give you a paper copy of this notice at any time.  You may also obtain a copy of this notice at our Web site,

Right to Breach Notification: You have the right to be notified when a breach of your unsecured protected health information has occurred.

Change to This Notice: We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.  We will post copies of this notice in the medical center.  This notice will contain the effective date.  In addition, each time you are in our facility for treatment, we will offer you a copy of the current notice in effect.

For More Information and to File a Complaint: If you have questions and would like additional information, you may contact the Privacy Officer at 715-483-0409.

If you believe your privacy rights have been violated, you may file a written compliant with our Privacy Officer or with the Secretary of the Department of Health and Human Services.  You will not be retaliated against for filing a complaint.