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, please contact our Privacy Officer at the address at the end of this notice.

Holy Family Memorial, Inc. provides healthcare to our patients and clients in partnership with physicians and other professionals and organizations. The information of privacy practices in this notice will be followed by:

  • Any healthcare professional who treats you at any of our locations.
  • All clinics, departments and units of our organization, including Lakeshore Pharmacy and Rehab Plus. (collectively, “Holy Family Memorial,” “we” or “us”).
  • All employed associates, employees, volunteers and other members of Holy Family Memorial’s workforce, including members of the medical staff and board members.
  • Any business associate with whom we may share health information so that they can perform services to, for or on behalf of Holy Family Memorial.


Each time you visit Holy Family Memorial a record of your visit is made. Typically this record contains your demographics, symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. We understand that medical information about you is personal. This information, often referred to as your health or medical record, serves as a:

  • Basis for planning your care and treatment.
  • Means of communicating among the many health professionals and others who contribute to your care.
  • Legal document describing the care you receive.
  • Means by which you or a third-party payer can verify that services billed were actually provided.
  • Tool in educating health professionals.
  • Source of information for public health officials charged with improving the health of the nation.
  • Tool for assessing and continually working to improve the care we give and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

  • Ensure its accuracy.
  • Better understand who, what, when, where and why others may access your information.
  • Make more informed decisions when authorizing disclosures to others.


We are required by law to:

  • Keep medical information about you private.
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you.
  • Follow the terms of the notice that is currently in effect.
  • Notify you if we do not agree to a requested restriction.
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We may change the provisions of this notice and our practices relating to use and disclosure of your medical information. The changes will be effective for all protected health information we already have, as well as for information obtained in the future. We will post the new notice at each registration area and on our web site at www.hfmhealth.org. You can obtain a paper copy of the current notice at any time upon request. The effective date is listed at the end of this notice.


  • You have a right to look at or get a copy of medical information that we used to make decisions about your care, with certain exceptions such as psychotherapy notes. You must make your request to review or obtain copies of your medical information in writing by completing a request form. We may charge a fee for the cost of copying, mailing or other related supplies.
  • If you believe that information in your medical record is incorrect or that important information is missing, you have the right to request that we amend the records. You must make this request in writing on our Request for Amendment form and include your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the information maintained by us; or if we determine that the record is accurate. You may appeal a decision by us not to amend a record by completing the appropriate form and submitting it to the Privacy Officer.
  • You have a right to an accounting of those instances where we have disclosed medical information about you, other than certain disclosures specified in the privacy regulations, such as for treatment, payment, and healthcare operations, or where you specifically authorized a disclosure. Your request must be in writing, specify the facility for which the accounting is to be provided, be directed to the facility where the record was created, and must state the time period for the accounting, which must be no more than 6 years (but not before April 14, 2003). You may request the accounting in paper or electronic form. The first disclosure request in a l2 month period is free; other requests will be charged according to our cost of producing the accounting. We will inform you of the cost before you incur any cost in advance.
  • If this notice was sent to you electronically, you have a right to a paper copy of this notice.
  • You have the right to request that medical information about you be communicated to you in a confidential manner. For example, you can request that we send mail to an address other than your home or contact you at a different telephone number. You must make your request in writing. You are not required to explain the request. We will accommodate all reasonable requests.
  • You may request, in writing, that we not use or disclose medical information about you for treatment, payment, healthcare operations or to persons who pay for or are involved in your care except when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request.

All requests or appeals pursuant to this section should be made in writing on our forms and submitted to our Privacy Officer at the address noted at the end of this notice.


  • We may use and disclose medical information about you for treatment (such as sending information about you to a specialist as part of a referral.) We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from the hospital.
  • We may use and disclose medical information about you to obtain payment for treatment (such as sending billing information to your insurance company or Medicare.) The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, and procedures and supplies used.
  • We may use and disclose medical information about you to support our healthcare operations (such as comparing patient data to improve treatment methods.) Members of the medical staff, risk management, quality improvement and the registry teams may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and services we provide. We may also use your information for obtaining accreditation and responding to regulatory agencies such as but not exclusive of JCAHO, and CARF.
  • We also disclose medical information when required by law, such as in response to a request from law enforcement in limited circumstances allowed by law or in response to a valid court order or federal subpoena.
  • We may also contact you by mail or by phone for appointment reminders or to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you.
  • Unless you notify our Privacy Officer of your objection in writing, we may contact you in an effort to raise money for Holy Family Memorial and its operations.
  • Unless you notify our Privacy Officer of your objections in writing, and with the exception of Behavioral Health and Chemical Dependency Patients, we will list in the patient directory your name, location in the hospital, your general medical condition (good, fair, etc) and your religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
  • Unless you notify our Privacy Officer in writing, and with the exception of Chemical Dependency Patients, health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
  • We have contracts with individuals and other entities (our business associates) who perform services for or on our behalf. Examples include laboratory tests, transcription services and the copy service we use when making copies of your health record. We may disclose your medical information to our business associates so they can perform the job we have asked them to do and bill you or your third party payer for the service rendered. We require all business associates to appropriately safeguard your information.
  • We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
  • We may disclose health information to a coroner or medical examiner consistent with applicable law to assist these individuals in carrying out their duties.
  • Consistent with applicable law, we may disclose information to organ procurement organizations or other entities engaged in procurement, banking or transplantation of organs or for the purpose of tissue donation and transplant.
  • If you are a member of the armed forces, we may release medical information about you as required by military command authorities as authorized by applicable law.
  • 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.
  • We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation and other similar programs established by law.
  • As required by law, we may disclose your health information to public health agencies or legal authorities charged with preventing or controlling disease, injury or disability, or monitoring healthcare data, such as the Office of Health Care Information. Your information also may be released to a health oversight agency or public health authority for purposes of conducting activities such as audits, investigations, inspection and licensure reviews and civil rights compliance.
  • If you are an inmate of a correctional institution or in the custody of law enforcement officials, we may disclose information to the medical staff or intake staff of the correctional institution or the Department of Corrections as needed for your health and to protect the health and safety of other individuals.
  • We may use and disclose medical information about you when we deem it necessary to prevent a serious threat to the health and safety of you or another person.
  • If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court order. We may also disclose medical information about you in response to a discovery request or other lawful process by someone else involved in the dispute, but only if we have obtained your permission or were unsuccessful in our efforts to obtain an order protecting the information requested.
  • We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
  • 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 to conduct special investigations.
  • We may release information to an employer to facilitate workplace medical surveillance as required by law.


If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you should document your concern and send it to Holy Family Memorial Inc.’s CEO at PO Box 1450 Manitowoc, WI 54221-1450. You may also contact the Holy Family Memorial Corporate Compliance Hotline at (920) 320-2886.

You also may send a written complaint to the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. Washington D.C. 20201 or phone the Secretary at (877) 696-6775 or (202) 619-0257.


If you have questions and would like additional information regarding our uses and disclosures of your health information, you may contact Holy Family Memorial, Inc.’s Privacy Officer in our Health Information Services Department at P.O. Box 1450, Manitowoc, WI 54221-1450.