Privacy Notice


Revised 2/13/2017

Privacy Notice - English Version

Privacy Notice - Spanish Version


Your health information
Each time you visit a Bellin Health facility or a Bellin Health provider for health care, a record of your visit is made. This record usually contains identification and financial information, as well as health information such as symptoms, diagnoses, test results, a description of the physical examination, and a treatment plan. This record of information is often referred to as your “medical record,” or “health information.” The following are examples of the purposes for which this information is used:

  • To plan for your care and treatment;
  • To communicate information among your health care professionals;
  • To legally record the care you received;
  • To verify to you or your insurance company what services were actually provided;
  • To help Bellin Health and all providers approved to practice at Bellin Health evaluate and improve the care they provide and the outcomes they achieve;
  • To provide a source of information for important health related research;
  • To educate health professionals and students; and
  • To provide a source of information for facility planning.

Bellin Health has always worked to protect your health information and will continue to do so. In addition, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) now requires Bellin Health to provide you with this notice describing our legal duties and privacy practices concerning your health information, as well as your rights related to your health information. This notice applies to all records of your health information held by Bellin Health, regardless of whether the record is written, computerized, or in any other form. We are required by law to keep your health information private and to follow the terms of this notice, or any revised version of this notice that is in effect.

Bellin Health reserves the right to change the privacy practices described in this notice and to change this notice to reflect our revised privacy practices. Changes to our privacy practices would apply to all health information maintained by us, including that which we obtained prior to changing this notice. If we change our privacy practices, you may read a summary of substantive changes on our website at You may obtain a revised copy of the privacy notice at the front desk of any of our facilities or on our website at

All of the below listed organizations and individuals agree to abide by the terms of this notice. These organizations and individuals will share your health information with each other as necessary for your treatment, to get paid for services, and to carry out health care operations activities such as quality assessment and improvement activities.

Who is covered by this notice
This notice covers the privacy practices of Bellin Health, which includes the health care professionals, including students, employees, other personnel, and volunteers providing services at Bellin Health. Bellin Health is several separate, but related organizations, which provide quality health care, train future health care professionals (such as doctors, nurses, and radiology technicians), and conduct health sciences research. Bellin Health is made up of the following organizations:

  • Bellin Hospital
  • Bellin Medical Group Clinics
  • Bellin Specialty Group Clinics
  • Bellin Health Employer Clinics
  • Bellin Home Health
  • Bellin Home Infusion
  • Bellin Health Home Care Equipment
  • Bellin Retail Pharmacies
  • Bellin Psychiatric Center
  • Bellin Cancer Center
  • Bellin Behavioral Health
  • Bellin Health Oconto Hospital

This notice also covers the privacy practices of all other providers approved to practice at any Bellin Health facility listed above. These providers include area physicians, podiatrists, dentists, nurse practitioners, physician assistants, and other health care professionals. References to “we,” “us,” or “our” in this notice mean the individuals and entities described above.

Who is not covered by this notice
This notice does not apply to care you receive from other providers in their personal offices or at other locations than the sites described above. Your providers may have their own polices and procedures that apply to your health information that they record or maintain outside of Bellin Health. You should review your provider's notice for information on how he or she will handle your health information outside of Bellin Health sites.

Shared Electronic Medical Record
We participate in an arrangement with ThedaCare to help facilitate access to health information that may be needed to provide you with care. As part of this arrangement, we have agreed to store health information of our patients in a jointly shared electronic medical record with the other health care provider participants in this arrangement. When it is needed, this shared electronic medical record will provide participants with access to health information essential to providing you with medical care. The need for this could occur, for example, if you were admitted to a hospital on an emergency basis and you were unconscious and could not provide important information about your health condition. Each participant in the shared electronic medical record has implemented policies and procedures governing appropriate access to health information in the shared electronic medical record in accordance with state and federal law. Any access to your health information that we store in the shared electronic medical record by a non-Bellin Health participant will only be made for the purposes described in this notice.

We are able to use your health information without your written authorization for the following purposes:
Treatment. We may use health information about you to provide medical treatment or health care services. We may disclose health information about you to doctors, nurses, technicians, students preparing for health care related careers, or other personnel who are involved in your care or treatment, including your primary care physician. For example, a physician 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 within Bellin Health may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. At shift change we will provide information to health care personnel that are vital for your care. For example, a respiratory therapist will provide a report about you to the next therapist who will be taking care of you. We may also share your health information in person or by phone, letter, fax, or electronically to people outside of Bellin Health who are involved in your medical care, such as your primary or referring physician, a long-term care facility, others we work with to provide services that are part of your care.

Payment. We may use and disclose your health information as necessary to obtain payment for the health care services we provide to you. Here are some cases where we use your health information without your written authorization for payment purposes. To check eligibility or to determine whether your insurance company will pay for the treatment, Bellin Health will tell your health insurance company about your treatment plan. Most of the time, this information is provided electronically (by computer), or by fax and or telephone.

In order for an insurance company or another agency 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 disclose necessary health information to an insurer or another agency for Bellin Health to receive payment for your medical bills.

Health Care Operations. We may use and disclose your health information for our organizational operations related to providing health care. Here are some cases where we use your health information without your written authorization for our operational purposes. We may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care delivered by us. These quality and cost improvement activities include evaluating the performance of your physicians, nurses, and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to other patients in similar situations. We contract with reputable and credible companies to help us analyze our data and compare ourselves to other health care providers to see where we can make improvements in the care and services we offer. We may also remove information that identifies you from this set of your health information so others may use it to study health care without learning your identity.

Bellin Health will also use or disclose your health information for teaching purposes, administrative activities, or for accreditation, certification, or licensing purposes. To remind you of your appointments for visits, tests and treatments, we may use your health information for appointment reminders. For example, we will view your medical record to determine the date and time of your next appointment with us, and then send you a reminder letter or call you to remind you of the appointment.

We will want to let you know of other treatments or services we offer that may improve or benefit your health. For example, we may notify patients with poor circulation to their legs of a new program we offer that might help them. We may communicate to you about good health practices, such as a mailing with information about how to lower cholesterol or stop smoking, and about health fairs, wellness classes, or support groups that we offer.

In order to provide more charity care or otherwise improve the health of your community, we may use your health information (for example, your name, address, phone number, and treatment dates) to contact you for fundraising purposes. You may opt-out of receiving any further fundraising communications from us.

Here are some instances when we can use and disclose health information without your written authorization:

  1. As required by law. We may use and disclose your health information when required to do so by local, state, or federal law.
  2. For public health activities. We may disclose your health information to certain public health authorities to help prevent or control disease, injury, or disability. This may include using your medical record to report certain diseases, injuries, birth or death information, reactions to medications or problems with products, or to notify people of recalls of products they may be using. We may also disclose your health information related to certain work-related illnesses and injuries to your employer.
  3. To report about victims of abuse or neglect. We may notify an appropriate government official if we believe a patient has been the victim of abuse, neglect, or domestic violence, but only if required or allowed to do so under state or other applicable law.
  4. For health oversight activities. We may disclose your health information to authorities for health oversight activities authorized by law, including audit, investigation, inspection, licensure, disciplinary, or other purposes related to oversight of the health care system or government benefit programs.
  5. For legal proceedings. We may disclose your health information in the course of legal proceedings as required or permitted under law. For example, we may disclose your health information in response to a court order.
  6. To law enforcement. We may disclose your health information to law enforcement officials for certain specific purposes. For example, we may disclose your health information to law enforcement as required to report certain injuries.
  7. For activities related to death. We may disclose your health information to coroners, medical examiners, and funeral directors so they can carry out their duties, such as identifying the body, determining cause of death, or in the case of funeral directors, to carry out funeral preparation activities.
  8. For organ, eye, or tissue donation. We may disclose your health information to entities involved in obtaining, banking, or transplanting organs, eyes, or tissue for donation or transplantation purposes.
  9. For research. Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research. Such research might involve studies related to evaluating the effectiveness of a treatment.
  10. To avoid a serious threat to health or safety. As required by law and standards of ethical conduct, we may disclose your health information to necessary authorities if we believe, in good faith, that disclosure is necessary to prevent or minimize a serious and imminent threat to your or the public’s health or safety.
  11. 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 disclose your health information to the proper authorities so they may carry out their duties under the law.
  12. For 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 illness.
  13. Bellin directory. During the inpatient admission process you will be asked if we can list in our directory your name, location in our facility, your general health condition (e.g., “stable,” or “unstable”), and your religious affiliation. The information about you contained in our directory will be disclosed to people who ask for you by name. However, the information about your religious affiliation will only be disclosed to clergy. You can tell us whether you object or agree regarding the use of your health information for directory purposes.
  14. To those involved with your care or payment for your care; for notification purposes. 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 disclose health information about you to those people that is relevant to the person's involvement in your care or payment for your care. We may also disclose your health information to family members or others involved in your care to notify them of your location and general condition, including your primary care physician. You have the right to object to these disclosures, unless you are incapacitated or there is an emergency. In those cases we will exercise professional judgment to determine if disclosure is in your best interests.
  15. For disaster relief efforts. We may disclose your health information to organizations authorized to handle disaster relief efforts.

When Bellin Health is required to obtain authorization to use or disclose your health information:
Except for the situations listed above, any other use or disclosure of your health information requires us to obtain your specific written authorization.

Special Situations. Some types of health information are specially protected under other state or federal laws and those laws may impose more restrictive requirements on disclosure of this information, even for purposes described above. When those more restrictive laws apply, we may need your specific written authorization to release these types of health information, even in some cases, for the purposes of treatment, payment, and health care operations. The types of health information that are subject to additional restrictions include HIV test results, and information related to treatment for mental illness, developmental disability, or alcohol or drug abuse.

Authorization Required for Certain Uses or Disclosures. We must obtain your written authorization for most uses or disclosures of the following: (1) psychotherapy notes; (2) uses or disclosures of your health information for marketing purposes; and (3) disclosures of your health information in exchange for direct or indirect remuneration to Bellin Heath.

Withdrawing authorization. If you do 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 Medical Records department at Bellin Hospital or to the Bellin site where you signed the authorization form. Please understand that we cannot take back any disclosures that were made before you withdrew your authorization.

You have several rights with regard to your health information. If you wish to exercise any of the following rights, please contact the Bellin Health Privacy Officer at (920) 433-3595. Specifically, you have the right:

  1. To inspect and copy your health information. You have the right to inspect and obtain a copy of your health information, with a few exceptions. For example, this right does not apply to psychotherapy notes or information compiled for judicial proceedings. In certain circumstances you may obtain a copy of your PHI in an electronic format and may request that we transmit such copy to any person or entity you designate. In addition, we may charge you a reasonable fee if you want a copy of your health information. If we deny your request to inspect or obtain a copy of your health information, you may submit a written request for a review of that decision.
  2. To request an amendment of your health information. If you believe your health information is incorrect, you may ask us to amend the information. You will be asked to make such a request in writing and to give a reason as to why your health information should be changed. However, if we did not create the health information that you believe is incorrect, or if we disagree with you and believe your health information is correct, we may deny your request. You may appeal to us in writing if we deny your request.
  3. To request restrictions on certain uses and disclosures. You have the right to notify us that you want restrictions placed on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment, our payment, or our health care operations activities. Except in the case of self-pay items (see section 4 below), Bellin Health is not legally required to agree to such restrictions. While we will consider your request, because of the number, complexity, and nature of the services we deliver we may not be able to grant the request. However, we are required to agree to your request for a restriction on the disclosure of your health information to a health plan if: (A) the disclosure is for the purposes of carrying out payment or health care operations and is not otherwise required by law; and (B) the health information pertains solely to a health care item or service for which you or another person on your behalf (other than your health plan), paid in full.
  4. To restrict disclosures of self-pay items to health plans. You have the right to restrict the disclosure of your health information (for payment or health care operations) to a health plan, if the health information pertains solely to items and services paid in full by you. We may not refuse this request.
  5. To receive confidential communications of health information. You have the right to request alternative means or locations where we may communicate your health information to you. For example, you may wish to receive a follow-up call from your provider at your work telephone number instead of your home number. Or you may wish to have your billing information sent to a private address. We will accommodate reasonable requests.
  6. To receive a report listing to whom we have disclosed your health information. In some limited instances, you have the right to request a report of the disclosures of your health information we have made during the previous six years, but the request cannot include disclosures that occurred before April 14, 2003. This written report must include the date of each disclosure, who received the disclosed health information, a brief description of the disclosed health information, and why the disclosure was made. We must comply with your request for the report within 60 days, unless you agree to a 30-day extension. We may not charge you for the report, unless you request such a report more than once per year. Our report will not include disclosures made to you or to your family or friends for care or payment, incidental disclosures, disclosures where you signed an authorization form, or disclosures for purposes of treatment, payment, or health care operations, information that is part of a limited data set or is part of our directory, or is disclosed for national security, or to law enforcement/correctional institutions in certain situations. In the future, you may also have the right to obtain an accounting of disclosures we make through an electronic health record where those disclosures were made during the previous three years for treatment, payment, or health care operations purposes.
  7. To receive notification about breaches of unsecured health information. You have a right to, and will receive, notification regarding any breaches of your unsecured health information.
  8. To 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 notice is available online at Or you may call the Privacy Officer at (920) 433-3595 to request a paper copy of this notice.
  9. To file a complaint. If you believe your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services. Complaints in no way affect how we care for you. To file a complaint with either Bellin Health or the Department of Health and Human Services, please contact the Bellin Health Grievance Coordinator at (920) 433-7869 who will provide you with the necessary assistance and paperwork. You may also file a complaint with the Department of Health and Human Services on your own without contacting us for assistance.

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact the Bellin Health Privacy Officer at (920) 433-3595.