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.



  • •Although your health record is the physical property of the healthcare facility that generated it, this information belongs to you.
  • You have the right to request a restriction on certain uses or disclosures of your health care information, including disclosures to a family member or other person involved with your care or with payment for your care. We do not have to grant the restriction.
  • You have the right to obtain a paper copy of the Notice of Privacy Practices upon request.
  • •You have a right to review your record, at no charge, or purchase photocopies. You must set up a time in advance with the facility.
  • •You have a right to know who has received your health information after 4/14/2003, except as provided by law.
  • •You have a right to request your health information by other means or in other locations to protect your privacy.
  • •You have the right to request an amendment to your protected health information. We will give you notice of our acceptance or denial of your request.
  • •You may be asked to make your request in writing and to give a reason as to why your health information should be changed.



  • This facility is required to maintain the privacy of your health information.
  • •To provide you with Notice of Privacy Practices with respect to information we collect and maintain about you.
  • •To abide by the terms of this notice.
  • •To accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
  • •We reserve the right to change our practices and to make the new provisions effective for all protected health information created or received prior to the effective date of the notice revision.
  • •Should our information practices change within the expiration date (“maximum of 1 year”) of your signed authorization to release information, we will mail a revised notice to your last known address.
  • We will not use or disclose your health information without your proper authorization, with the exception of applicable state and federal laws.



  • We will use your health information to provide you with treatment or services. For example: your treatment team members might discuss your        medical/health information in order to develop and carry out a plan for your services.
  • We will use your health information for payment and operations. For example: a bill might be sent to you or a third-party payor or we may receive a claim from your service provider. This may include information that identifies you, as well as procedures and supplies used.
  • We will use your health information for regular service operations. For example: Case management staff, risk or quality improvement manager, or the quality improvement team may use information in your service record to assess the care and outcomes in your case. This information could be used to improve the quality and effectiveness of the services we provide.
  • Business Associates: There are some services provided in our organization through contacts with business associates or service providers. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.
  • Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and except for religious affiliation to other people who ask for you by name.
  • Notification: We may use or disclose information to notify or assist in notifying a family member, representative, or another person responsible for your care, your location and general condition. In addition, we 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.
  • Communication with Other Individuals: Health information will only be shared with other individuals if we have your written authorization or qualified under legal exemptions. We may contact you to provide appointment reminders. Health professionals, using their best judgment, may disclose to a family member, other relative or any person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
  • Research: Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.
  • Funeral Directors: We may disclose health information to coroners, medical examiners and funeral directors consistent with applicable law to carry out their duties.
  • Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement,banking or transplantation of organs for the purpose of tissue donation and transplant.
  • Marketing: We may contact you with information on community resources or other health-related benefits and services that may be of interest to you.
  • Food and Drug Administration: We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.
  • Workers Compensation: We 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.
  • Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
  • For Military, National Security or Incarceration/Law Enforcement: 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 disclose your health information to the proper authorities so they may carry out their duties under the law.
  • For Health Oversight Activities: We may disclose your health information to authorities for audit, investigation, inspection, licensure, disciplinary or other purposes related to oversight of the health care system or government benefit programs.


*Uses or disclosures other than described above will be made only with your written authorization. You have the right to revoke this authorization except to the extent that action has already been taken.



If you believe your privacy rights have been violated, you can file a complaint with Lakeland Care at the office of the Compliance Manager, N6654 Rolling Meadows Drive, Fond du Lac, WI 54937, Telephone (920) 906-5100. There will be no retaliation for filing a complaint.


Any person who believes that a covered entity is not complying with the requirements of HIPAA may file a complaint with the Secretary of Health and Human Services within 180 days of the occurrence. Complaints may be filed in writing with:


The Office of Civil Rights
U.S. Department of Health and Human
Services, 233 N. Michigan Ave.,Suite 240
Chicago, IL 60601


Phone: (312) 886-2359
Fax: (312) 886-1807
TDD: (312) 353-5693


Consumers will not be asked to waive their right to file a complaint in order to receive treatment or services and the filing of a complaint will not interfere with their health care. Office of Civil Rights 1-866-627-7748.