Woods & Water Medical Center

1019 S. Knowles Avenue • New Richmond, WI • 54017 • 715.246.6561 • www.wwcm@world.com

HIPAA Privacy Policy

1) PURPOSE
A. Ensures confidentiality, integrity, and availability of all electronic protected health information (ePHI)
that a covered entity (CE) or business associate (BA) creates, receives, maintains, or transmits.
B. Protect against any reasonably anticipated threats or hazards to the security or integrity of such ePHI.

2) SCOPE
A. This policy applies to all organization’s employees, management, contractors, student interns, and
volunteers.
B. This policy describes the organization’s objectives and policies regarding maintaining the privacy of
patient information.

3) RESPONSIBILITIES
A. Executives/Management
i) Establish program objectives.
ii) Approve privacy policy.
iii) Provide training for work force.
iv) Enforce sanctions.
v) Designate Privacy Official.
B. Privacy Official
i) Develops privacy policies and procedures.
ii) Coordinates and implements policy through organization’s departments.
iii) Oversees training.
iv) Receives and processes privacy complaints.
v) Processes individual rights requests.
(1) Right to access/copy protected health information (PHI).
(2) Right to amend PHI.
(3) Right to restrict use/disclosure.
(4) Right to confidential communications.
(5) Right to an accounting of disclosures.
(6) Right to file a complaint.
vi) Ensures retention of HIPPA policies and procedures, complaints, and investigative materials to meet
compliance requirements.
C. Legal Counsel (or Privacy Official)
i) Processes Business Associate Agreements (BAA)
(1) Conducts business associate inventory.
(2) Develops and coordinates BAA template.
(3) Conducts annual review/update.
ii) Corporate Compliance Officer
(1) Assists in development and execution of the HIPPA Privacy Policy and promulgation of operating
procedures.
(2) Assists and supports the Privacy Official.
(3) Provides support for HIPPA compliance activities.

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 iii) Medical Records Director
(1) Implements organization’s privacy policy for medical records.
(2) Provides administrative and physical safeguards for the protection of client health information.
iv) Training Director
(1) Develops and implements privacy training program as described in Section 11 of the policy.
(2) Documents the delivery of privacy training to all work force members.
v) Employee
(1) Understand and comply with organization’s policies regarding patient confidentiality and
privacy.

4) NOTICE OF PRIVACY PRACTICES (NPP)

A. The organization will make a “best effort” attempt to receive acknowledgement of receipt of NPP from
patient and document such in the patient’s medical record.

5) USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

A. Routine uses.
B. Process of disclosing client information.
C. Personal representatives.

6) INDIVIDUAL RIGHTS
A. Right to access/copy PHI.
B. Right to amend PHI.
C. Right to restrict use or disclosure.
D. Right to confidential communications.
E. Right to an accounting of disclosures.
F. Right to file a complaint.

7) SAFEGUARDS FOR THE PROTECTION OF PHI

A. Administrative safeguards.
B. Physical safeguards.
C. Technical safeguards.

8) WORK FORCE TRAINING

A. New staff member training.
B. Recurrent training.
C. Special function training.

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