• General Disclaimer
• Nondiscrimination Policy Summary
• Nondiscrimination Policy
• HIPAA Notices

Nondiscrimination Policy

Winneshiek Medical Center 
Nondiscrimination Policy
Effective:  August 1989
Revised:  August 1996, April 2003

To define the organization’s policy regarding nondiscrimination.

Standard

In furtherance of our nation's commitment to end discrimination, and in accordance with the provisions of Section 504 of the Rehabilitation Act of 1973, Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issues pursuant to the Acts, Title 45 Code of Federal Regulations Part 80, 84, and 91, and all other nondiscriminatory acts protecting the rights of the disabled and other individuals or groups, WMC has established the following policy.

Procedure

Policy Statement

As a recipient of federal financial assistance, Winneshiek Medical Center does not exclude from participation, deny benefits to, or otherwise discriminate against any person on the basis of race, color, gender, age, national origin, religion, or disability in admission to, participation in, or receipt of services and benefits of any of its programs and activities or in employment therein, whether carried out by Winneshiek Medical Center directly or through a contractor or any other entity with whom Winneshiek Medical Center arranges to carry out its programs and activities.

Winneshiek Medical Center does not discriminate in patient admissions, room assignments, patient services, or hiring on the basis of race, color, gender, age, national origin, religion, or disability.

Winneshiek Medical Center does not deny admission to people with communicable diseases including, but not limited to HIV, MRSA, and hepatitis B, as long as we have the appropriate medical facilities and services to care for them.

Communication of Policy

Winneshiek Medical Center's notice of nondiscrimination is communicated to all participants, beneficiaries, and other interested persons via multiple methods, including but not limited to the following:

The notice is placed in the local newspaper on an annual basis.

The notice is posted on facility bulletin boards.

The notice is posted in registration areas.

The notice is written on the organization’s employment application.

The entire policy is posted on the organization’s web page.

Communication with Sensory or Speech Impaired Individuals

Winneshiek Medical Center assures that all individuals are able to receive effective notices, including nondiscrimination and notices concerning benefits or services or information concerning waivers of rights or consent to treatment, regardless of their disability.  (See Communication with Sensory or Speech Impaired Individuals policy.)

Complaint Process

Winneshiek Medical Center has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by the U.S. Department of Health and Human Services regulations (45 C.F.R. Part 84), implementing Section 504 of the Rehabilitation Act of 1973 as amended (29 U.S.C. 794).  Section 504 states, in part, that “no otherwise qualified disabled individual…shall solely be reason of his/her disability, be excluded from participation in, be denied benefits of, or be subject to discrimination under any program or activity receiving federal financial assistance…”  The law and regulation may be examined in the office of Chief Administrative Officer, 901 Montgomery Street, Decorah, Iowa 52101, Phone 563-382-2911, who has been designated to the efforts of Winneshiek Medical Center to comply with the regulations.

1. A complaint should be in writing, contain the name and address of the person filing it, and briefly describe the discriminatory act.

2. A complaint should be filed in the office of the Section 504 coordinator within 30 days after the person filing the complaint becomes aware of the alleged discriminatory act.

3. The Chief Administrative Officer, or designee, will investigate the complaint. The investigation will be informal but thorough, affording all interested persons and their representatives an opportunity to submit evidence relevant to the complaint.

4. The Chief Administrative Officer shall issue a written decision determining the validity of the complaint no later than 30 days after its filing.

5. The Section 504 coordinator shall maintain the files and records relating to all complaints filed. The Section 504 coordinator may assist persons with the preparations and filing of complaints, and advise the Chief Administrative Officer concerning their resolution.

6. An individual who files a complaint may pursue other remedies. This includes filing with:

Office for Civil Rights
U.S. Department of Health and Human Services
601 East 12th Street - Room 248
Kansas City, Missouri 54106
Voice Phone (816)426-7278
FAX (816)426-3686
TDD (816)426-7065

These rules shall be liberally construed to protect the substantial rights of interested persons to meeting appropriate due process standards and assure Winneshiek Medical Center's compliance with Section 504 of the regulations.

Contact Information

In case of questions regarding this policy, or in the event of a desire to file a complaint alleging violations of the above, please contact:

Winneshiek Medical Center
Allan Atkinson, Chief Administrative Officer
901 Montgomery Street
Decorah, IA 52101
Phone: 563-382-2911
TDD: 800-735-2943

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HIPAA Notices

Effective Date:April 1, 2005

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.

If you have any questions about this notice, please contact the Privacy Officer/Health Information Management Director.

WHO WILL FOLLOW THIS NOTICE
This notice describes the medical center?s practices and that of:
- Any healthcare professional authorized to enter information into your chart.
- All departments and units of the medical center.
- Any member of a volunteer group we allow to help you while you are at the medical center.
- All employees, staff and other personnel of Winneshiek Medical Center, including the offsite medical clinic in Mabel, MN and Rehab clinics at Postville, IA, Calmar, IA, and Spring Grove, MN.
- Decorah Clinic Provider - Mayo Health System, practicing at Winneshiek Medical Center.
- All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or healthcare operations purposes described in this notice.

OUR PLEDGE REGARDING INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting information about you. We create a record of the care and services you receive at the medical center. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the medical center, whether made by medical center personnel 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 the doctor?s office or clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of information.

We are required by law to:
- make sure that medical information that identifies you is kept private;
- give you this notice of our legal duties and privacy practices with respect to medical information about you; and
- follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use information about you to provide you with medical treatment or services. We may disclose information about you to doctors, nurses, technicians, medical students, or other medical center personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the medical center also may share information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the medical center who may be involved in your medical care such as family members, clergy or others we use to provide services that are part of your care.

For 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 and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the medical center so your health plan will pay us or reimburse you for the surgery. We may also 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.

For Healthcare Operations: We may use and disclose medical information about you for healthcare operations. These uses and disclosures are necessary to run the medical center and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services the medical center should offer, what services are not needed, and whether certain new treatments are effective.

We may also disclose information to doctors, nurses, technicians, medical students, to promote learning and development of future healthcare providers, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are.

Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. For example, mammography reminders.
Follow-Up We may use and disclose medical information to contact you for follow-up phone calls regarding your medical care. We may also use and disclose medical information to contact you for a written follow-up survey regarding the care you received.

Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. For example, support groups.

Fundraising/Marketing Activities: We may use medical information about you to contact you in an effort to raise money for the medical center and its operations. We may disclose medical information to a foundation related to the medical center so that the foundation may contact you in raising money for the medical center. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services. If you do not want the medical center to contact you for fundraising efforts, you must notify the Privacy Officer in writing. For example, newsletters.

Patient Directory: We may include certain limited information about you in the directory while you are a patient at the medical center. This information may include your name, location in the medical center, and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi or other members of your religion who ask to see the medical center patients, even if they don?t ask for you by name. This is so your family, friends and clergy can visit you in the medical center and generally know how you are doing.
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 medical center. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Research: Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients? need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the medical center. We will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the medical center.

As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or 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 the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS
Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans:  If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers? Compensation: We may release medical information about you for workers? compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:

- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a patient has been the victim of abuse or neglect. We will only make this disclosure when required or authorized by law.

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. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release medical information if asked to do so by a law enforcement official under the following circumstances:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person?s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the medical center; and
- In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the medical center to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING INFORMATION ABOUT YOU
You have the following rights regarding information we maintain about you:
Right to Inspect and Copy You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer. 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.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the medical center will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that 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 for as long as the information is kept by or for the medical center.

To request an amendment, your request must be made in writing and submitted to the Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for the medical center;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.

Right to an Accounting of Disclosures: You have the right to request an ?accounting of disclosures.? 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 in writing to the Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. 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 Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

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 can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
 
You may obtain a copy of this notice at our website, www.winmedical.org.

To obtain a paper copy of this notice, ask the registration staff upon registering.

CHANGES 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 a copy of the current notice in the medical center. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the medical center for treatment or healthcare services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the medical center or with the Secretary of the Department of Health and Human Services. To file a complaint with the medical center, contact the Winneshiek Medical Center Privacy Officer 563-387-3106. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

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