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NOTICE OF PRIVACY PRACTICES
Effective Date 4-14-04
TO: Employees/Named Insureds & Dependents

RIVERSIDE MEDICAL CENTER (RMC), INC. HEALTH PLANS

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, contact the RMC Health Plans Privacy Officer/Director of Human Resources.

WHO WILL FOLLOW THIS NOTICE. During the course of providing you with health coverage, the Health, Healthcare Reimbursement Arrangement (HRA), Dental, Health Care Reimbursement Account (HCRA) Plans, and/or Employee Assistance Program (EAP) ("Health Plans") will have access to information about you that is deemed to be "protected health information"(PHI), by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The procedures outlined below have been added to the Health Plans to ensure that your PHI is treated with the level of protection required by HIPAA. This notice describes the PHI practices of your Health Plans and that of any third party that assists in the administration of your Health Plans claims.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. Your personal physician, dentist, or other health care provider may have different policies or notices regarding the use and disclosure of your medical information created in the physician or dental 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 medical 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.

Some PHI may be disclosed to certain employees of Riverside Medical Center ("Employer"). These employees are Human Resources Department personnel. These individuals may only use your PHI for Plan administration functions including those described below, provided they do not violate the provisions set forth herein. Any employee of Riverside Medical Center who violates the rules for handling PHI established herein will be subject to RMC Performance Improvement Guidelines (disciplinary policy).

The Employer has certified that it will comply with the privacy procedures set forth herein. Employer may not use or disclose your PHI other than as provided herein or as required by law. Any agents or subcontractors who are provided your PHI must agree to be bound by the restrictions and conditions concerning your PHI found herein. Your PHI may not be used for any employment-related actions or decisions. Your Employer must report to the Health Plans any uses or disclosures of your PHI of which the Employer becomes aware that are inconsistent with the provisions set forth herein.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU. The following categories describe different ways that we use and disclose medical information for purposes of Health Plans administration. 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 (as described in applicable regulations). If needed, we may use medical information about you to facilitate medical treatment or services. For Payment (as described in applicable regulations). We may use and disclose medical information about you to determine eligibility for Health Plans benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Health Plans, or to coordinate Health Plans coverage. Likewise, we may share medical information with another entity to assist with the adjudication or subrogation of medical claims or to another health plan to coordinate benefit payments. For Health Care Operations (as described in applicable regulations). We may use and disclose medical information about you for other Health Plans operations. These uses and disclosures are necessary to run the Health Plans. For example, we may use medical information in connection with conducting quality assessment and improvement activities; conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; business planning and development such as cost management; and business management and general Health Plans administrative activities. As Required By Law. We will disclose medical information about you when required 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

Disclosure to Health Plan Sponsor. Information may be disclosed to another health plan maintained by your Employer for purposes of facilitating claims payments under that plan. In addition, medical information may be disclosed to RMC Human Resources Department personnel solely for purposes of administering benefits under the Plan. 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 organ donation bank, as necessary to facilitate 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 authorities. We may also release medical 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 (prevent/control disease,injury or disability). Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care 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 in response to a court order, subpoena, warrant, summons or similar process. 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 hospital 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, counter-intelligence, and other national security activities authorized by law. 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 for (1) the institution to provide you with health care; (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 MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical 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 Health Plans benefits. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the RMC Health Plans Privacy Officer/Director of Human Resources. 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. HIPAA provides several important exceptions to your right to access your PHI. For example, you will not be permitted to access psychotherapy notes or information compiled in anticipation of, or for use in, a civil, criminal or administrative action or proceeding. Employer will not allow you to access your PHI if these or any of the exceptions permitted under HIPAA apply. If you are denied access to medical information, you may request that the denial be reviewed. 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 Health Plans. To request an amendment, your request must be made in writing and submitted to the RMC Health Plans Privacy Officer/Director of Human Resources. 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 is not part of the medical information kept by or for the Health Plans; 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 information which you would be permitted to inspect and copy; or is accurate and complete. Employer must act on your request for an amendment of your PHI no later than 60 days after receipt of your request. Employer may extend the time for making a decision for no more than 30 days, but it must provide you with a written explanation for the delay. If Employer denies your request, it must provide you a written explanation for the denial and an explanation of your right to submit a written statement disagreeing with the denial. Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures" (other than disclosures you authorized in writing) where such disclosure was made for any purpose other than treatment, payment, or health care operations. To request this list or accounting of disclosures, you must submit your request in writing to the RMC Health Plans Privacy Officer/Director of Human Resources. Your request must state a time period which may not be longer than six years and may not include dates before April 2003. Your request should indicate in what form you want the list (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. Note that HIPAA provides several important exceptions to your right to an accounting of the disclosures of your PHI. Employer will not include in your accounting any of the disclosures for which there is an exception under HIPAA. Employer must act on your request for an accounting of the disclosures of your PHI no later than 60 days after receipt of the request. Employer may extend the time for providing you an accounting by no more than 30 days, but it must provide you a written explanation for the delay. You may request one accounting in any 12-month period free of charge. Employer will impose a fee for each subsequent request within the 12-month period. 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. To obtain an electronic or paper copy of this notice, contact the RMC Health Plans Privacy Officer/Director of Human Resources. Employer must make its internal practices, books and records related to the use and disclosure of PHI received from the Health Plans available to the Secretary of Health and Human Services for purposes of determining compliance by the Health Plans with these privacy protections. When Employer no longer needs PHI disclosed to it by the Health Plans, for the purposes for which the PHI was disclosed, Employer must, if feasible, return or destroy the PHI that is no longer needed. If this is not feasible, the Employer must limit further uses and disclosures of the PHI to those purposes that make the return or destruction of the PHI infeasible.

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 on the RMC Intranet site. The notice will contain the effective date at the top of the first page.

COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the Health Plans or with the Secretary of the Department of Health and Human Services (address provided upon request to file a complaint). To file a complaint with the Health Plans, contact the RMC Health Plans Privacy Officer/Director of Human Resources. 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 authorization. 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 medical 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.

Contact for questions, requests, or complaints: RMC Health Plans Privacy Officer/Director of Human Resources, 800 Riverside Drive, Waupaca, WI 54981, 715-258-1237, hr@riversidemedical.org. A copy of this notice is also available on the RMC Intranet and at www.riversidemedical.org.