Stoughton Hospital and the members of its Medical Staff must maintain the privacy of your personal medical information and give you this notice that describes our legal duties and privacy practices concerning your personal medical information.  In general, when we release your medical information, we must release only the information we need to achieve the purpose of the use or disclosure.  However, all of your personal medical information will be available to be released to you, to a provider regarding your treatment, or due to a legal requirement.  We must follow the privacy practices described in this notice.

 In compliance with federal and state laws, we may make your Protected Health Information available electronically through an electronic health information exchange to other health care providers and health plans that request your information for purposes of Treatment, Payment, and Health Care Operations; and to public health entities as permitted by law.  Participation in an electronic health information exchange also lets us see other providers’ and health plans’ information about you for purposes of Treatment, Payment, and Health Care Operations.

 However, we reserve the right to change the privacy practices described in this notice, in accordance with the law.  Changes to our privacy practices would apply to all medical information we maintain.  If we change our privacy practices the revised notice will be posted in our hospital lobby and will also be available on the hospital website at

 How we may use and disclose medical information about you.  The following categories describe different ways that we use and disclose medical 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. 


  1. Treatment.  [We may disclose medical information about you to doctors, nurses, technicians, health care students, clergy, or others who are involved in your care. For example, a doctor may use the information in your medical record to determine which treatment option, such as a drug or surgery, best addresses your health needs.  The treatment selected will be documented in your medical record, so that other health care professionals can make informed decisions about your care. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.]
  2. Payment. [In order for an insurance company or third party to pay for your treatment, we must submit a bill that identifies you, your diagnosis, and the treatment provided to you.  As a result, we will pass such medical information onto an insurer in order to help receive payment for your medical bills.  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]
  3. Health Care Operations[We may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care we deliver.  These quality and cost improvement activities may include evaluating the performance of your doctors, nurses and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to patients in similar situations.]

 In addition, we may want to use your medical information for appointment reminders.  For example, we may look at your medical record to determine the date and time of your next appointment with us, and then send you a reminder letter or telephone you to help you remember the appointment.  Or, we may look at your medical information and decide that another treatment or a new service we offer may interest you.  For example, we may contact a diabetic patient to notify them that we have a new diabetes support group that may be of interest to them.

    4. Fundraising. Stoughton Hospital may use contact information (name, address, telephone number, dates of service, age and gender and the department(s) in which you received services) to contact you in the future to raise money for Stoughton Hospital.  We may also provide this name to our related foundation for the same purpose.  The money raised will be used to expand and improve the services and programs we provide the community.  If you do not wish to be contacted for fundraising efforts, you must notify the Stoughton Hospital Foundation via email to or phone 608-873-2328.

   5. As required or permitted by lawSometimes we must report some of your medical information to legal authorities, such as law enforcement officials, court officials, or government agencies.  For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order. We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety. 

    6. For public health activitiesWe may be required to report your medical 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/death information, or information of concern to the Food and Drug Administration.

     7. For health oversight activities.  We may disclose your medical information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs. 

       8. For activities related to deathWe may disclose your medical 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 cause of death, or in the case of funeral directors, to carry out funeral preparation activities.

     9. For organ, eye or tissue donationWe may disclose your medical information to people involved with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.

    10. For research.  Under certain circumstances, and only after a special approval process, we may use and disclose your medical information to help conduct research.  Such research might try to find out whether a certain treatment is effective in curing an illness.

     11. To avoid a serious threat to health or safetyAs required by law and standards of ethical conduct, we may release your medical information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public’s health or safety.

    12. 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, we may release your medical information to the proper authorities so they may carry out their duties under the law. 

     13. For workers’ compensationWe may disclose your medical 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 illness.

     14. Stoughton Hospital Directory.  Unless you object, we may use your medical information, such as your name, location in our facility, your general health condition (e.g., “stable,” or “unstable”), and your religious affiliation for our directory.  The information about you contained in our directory will be released to people who ask for you by name.  However, the information about your religious affiliation will only be disclosed to clergy.  We may allow you to agree or disagree orally regarding the use of your medical information for directory purposes.

     15.  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, we may release important medical information about you to those people.  The information released to these people may include your location within our facility, your general condition, or death.  You have the right to object to such disclosure, unless you are unable to function or there is an emergency.  In addition, we may release your medical information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location or health status.  We may allow you to agree or disagree orally to such release, unless there is an emergency. 

   If your treatment here is for alcohol or drug related illness, mental health disorders, or HIV/AIDs related illness, your information will not be released without your written authorization.

    16. For Participation in Health Information Exchanges. Stoughton Hospital participates in a regional arrangement of health care organizations, who have agreed to work with each other, to facilitate access to 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, this regional arrangement will allow us to make your health information from other participants available to those who need it to treat you at the hospital.  When it is needed, ready access to your health information means better care for you.  We store health information about our patients in a joint electronic medical record with other health care providers who participate in this regional arrangement.

    17. For Other Uses of Medical Information. We will not use or disclose your health information without written authorization from you,“except as outlined in our notice of privacy practices” below   For example, marketing and the sale of protected health information require your authorization.

 NOTE:  Except for the situations listed above, we must obtain your specific written authorization for any other release of your medical information.  An authorization is different than consent.  One primary difference is that unlike with consents, a provider must treat you even if you do not wish to sign an authorization form. If you sign an authorization form, 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 Health Information Department, (608) 873-2224.

 Your Medical information Rights

 You have several rights with regard to your medical information.  If you wish to exercise any of the following rights, please contact any hospital manager, administrative staff member, or the hospital's Privacy Officer (608) 873-2383.  Specifically, you have the right to:


  1. Inspect and copy your medical informationWith a few exceptions, you have the right to inspect and obtain a copy of your medical information.  However, this right does not apply to, for example, psychotherapy notes or information gathered for judicial proceedings. In addition, we may charge you a reasonable fee if you want a copy of your medical information.
  2. Request to correct your medical informationIf you believe your medical 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 medical information should be changed.  However, if we did not create the medical information that you believe is incorrect, or if we disagree with you and believe your medical information is correct, we may deny your request.
  3. Request restrictions on certain uses and disclosures.  You have the right to ask for restrictions on how your medical information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities.  Or, you may want to limit the medical information provided to family or friends involved in your care or payment of medical bills.  You may also want to limit the medical information provided to authorities involved with disaster relief efforts.  However, we are not required to agree in all circumstances to your requested restriction. 

   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.

   4. As applicable, receive confidential communication of medical informationYou have the right to ask that we communicate your medical 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.

   5. Receive a record of disclosures of your medical informationIn some limited instances, you have the right to ask for a list of the disclosures of your medical information we have made during the previous six years, but the request cannot include dates before April 14, 2003.  This list must include the date of each disclosure, who received the disclosed medical information, a brief description of the medical information disclosed, and why the disclosure was made.  We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.  We will not include in the list any disclosures made to you, or for purposes of treatment, payment, health care operations, our directory, national security, law enforcement/corrections, and certain health oversight activities.

   6. 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.  This privacy notice is also available on the Stoughton Hospital website at 

   7. File a ComplaintIf 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 the hospital's Privacy Officer, Health Information Department, (608) 873-2383, who will provide you with the necessary assistance and paperwork.

    8.  Notice of Breaches. You have the right to receive notifications of breaches of your unsecured medical information.

    9. Right to Request Restrictions to a Health Plan. You have the right to request, in writing, on the day of discharge, a restriction or limitation on the medical information we disclose about you to a health plan. You may request this for purposes of payment or health care operations if you, or someone on your behalf, has paid for the health care item or service out of pocket in full.  Stoughton Hospital may not refuse this request.


Again, if you have any questions or concerns regarding your privacy rights or the information in this notice, please contact our Privacy Officer, Health Information Department, (608) 873-2383.

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

 This Notice of Medical Information Privacy was Revised April 22, 2005.

 This Notice of Medical Information Privacy was Revised September 22, 2013.

   Form #6032   Rev. 09/22/2013                                                                                                        




© 2012 Stoughton Hospital · Affililiated with SSM Health Care of Wisconsin · All Rights Reserved