Notice of Privacy Practices

Your Information – Your Rights – Our Responsibilities

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.

Brewster village is required by law to maintain the privacy of your health information and is also required to provide you with this Notice describing our legal duties and privacy practices as well as your privacy rights with respect to your health information. We will follow the privacy practices described in this notice.

Your Rights

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you:

Get an electronic or paper copy of your medical record

  • You can ask to see or receive an electronic or paper copy of your medical record and other health information we have about you, including billing records.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete.
  • We may say no to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to communicate with you in a specific way, by alternative means or in alternative locations. For example, you may ask that we contact you at your office phone instead of your home phone or to send mail to a different address. We will say yes to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share your health information even if it affects your treatment or our payment or health care operations. We are not required to agree to your request, and we may say no if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our health care operations with your health insurer. We will say yes unless we are required to share that information by law.

Get a list of those with whom we’ve shared information

  • You can ask for an accounting of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why excluding disclosures related to treatment, payment, and health care operations and certain other disclosures (such as any you asked us to make).
  • We will provide one free accounting a year but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically and even if you have previously received one. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can ask questions, share your concerns, exercise your rights or make a complaint if you feel we have violated your rights by contacting our HIPAA Privacy Officer, who will give you with any needed assistance. Please contact:

Kristina Wallace
Health Information Coordinator/HIPAA Privacy Officer
3300 W. Brewster Street
Appleton WI 54914
Phone: 920-225-1982

  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
  • We will not retaliate against you for filing a complaint.

Your Choices

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a facility directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

Our Uses and Disclosures

We typically use or share your health information in the following ways:


We can use your health information and share it with other professionals who are treating you, coordinating or managing your health care. For example, we may use your information to refer you to another physician or a hospital to consult in your care.


We can use and share your health information to bill and obtain payment from health plans or other entities. For example, we may give information about you to your health insurance plan so your insurer will pay for services provided to you.

Health Care Operations:

We can use and share your health information to run our practice, improve your care, evaluate the performance of health care providers, comply with the law and contact you when necessary. For example, we use health information about you to manage your treatment and services.

How Else Can We Use Or Share Your Health Information?

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet certain legal conditions before we can share your information for these purposes.

Public health and safety issues:

We can share health information about you for certain situations such as:

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety


Under certain circumstances, we can use or share your information to conduct medical research.

Comply with the law:

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with privacy laws.

Organ and tissue donation:

We can share health information about you with organ procurement organizations.

Coroners and funeral directors:

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Workers’ compensation, law enforcement, and other government requests:

We can use or share health information about you:

  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Lawsuits and legal proceedings:

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Facility Directory:

Unless you notify us that you object, we may disclose your name, location in our facility, general condition (i.e. stable or unstable) and religious affiliation to individuals who ask for you by name. Religious affiliation will only be disclosed to clergy or other designated representatives of the church.

Health information availability after death:

We may use or disclose your health information without your authorization 50 years after the date of your death unless you have informed us you wish to restrict this use and disclosure of your health information. For more information see:

Our Responsibilities 

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:

Changes to the Terms of This Notice

Changes to the Terms of This Notice

Brewster Village reserves the right to change the terms of this notice in the event its practices must change to assure compliance with privacy laws. Changes will apply to all information we have about you. The new notice will be posted in a prominent location within our facility, on our web site and paper copies will otherwise be made available upon request.

Original Version: 04/14/2003
Effective Date of this Notice: 10/17/2013

Brewster Village

Contact Us

Brewster Village
3300 W. Brewster Street
Appleton, WI 54914-6444

Leave A Message

2 + 9 =