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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Communication with Patients Outside of the Clinical Setting
Policy Number: 6.24
Effective Date: December 1, 2015
Chapter: Medical Records
To establish guidelines and parameters by which UWHC staff may communicate protected health
information to individuals outside of the clinical setting in a manner that protects patient's confidentiality
and meets state and federal requirements.
A. UWHC staff is permitted to communicate protected health information to patients, their legally
authorized representatives, their emergency contact, and/or their guarantor/insurance subscriber
outside of the clinical setting for a variety of purposes (e.g. for follow-up treatment, or to send a
bill etc.), provided that reasonable measures (set forth below) are undertaken to protect the
privacy and confidentiality of patients protected health information (PHI). PHI is individually
identifiable health information that is transmitted, or maintained in any form, including oral,
written, or electronic. Protected health information includes demographic, health information, and
B. Patients or their legally authorized representatives have a right to request that we communicate
with them in a manner that is different than our standard practices ("alternative
communications.") Under federal law, UWHC is required to accommodate all reasonable
requests. It is reasonable for UWHC to direct all future communications to a particular address or
phone number. It is not reasonable for UWHC to direct some communications to one address and
some to another, or to accept a request that communications be made to someone other than the
patient or the patient's legally authorized representative. It is also not reasonable for UWHC to
accept a request that no communications be made to the individual.
C. Clinical sites may choose to adopt stricter procedures as necessary to protect the privacy of their
A. Standard Practices for Communicating with Patients
1. Written correspondence
a. UWHC will mail written communications to the patient, the patient's legally
authorized representative, or the guarantor/insurance subscriber's home address.
Exception: the individual requests an alternative address (see III B)
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b. Written correspondence should be sent in a sealed envelope, not a post card.
c. Written correspondence should include the site's mail code rather than the
specific clinic's name in the return address.
2. Phone calls
a. UWHC will make phone calls using the patient, the patient's legally authorized
representative, or the guarantor/insurance subscriber's home and/or work phone
Exception: (1) the individual requests an alternative phone number (see III
B). (2) the individual provides staff with a phone number to call them.
b. All phone communications should be made directly with the patient, the patient's
legally authorized representative, the guarantor/insurance subscriber, or the
patient's emergency contact person.
3. Answering machine/voicemail messages
a. Staff may leave the minimum amount of information necessary to communicate a
message to the patient. "Minimum amount of information" means leaving as
little information as possible, while conveying what is important or
necessary. The following are examples, not definitive lists, of what is generally
considered appropriate messages to leave:
i. "Please call (person's name) at your doctor's office at ... "
ii. "Please call Dr. (name) office at..."
iii. "This is to remind you that you have an appointment at UW hospital at
2:00 p.m. If you have any questions please call..."
iv. "Please contact the UW Hospital Business Office at ..."
b. In some cases, the minimum amount of information may be a more "detailed
message" than described above because it is necessary to provide the individual
with information for safety purposes or for the convenience of the patient or the
patient's legally authorized representative. In these cases, if time permits, UWHC
staff should attempt to contact the patient or legally authorized representative and
give them an opportunity to call back prior to leaving a more detailed
message. Examples of appropriate messages to leave in these cases include the
i. "This is to remind you that you have a procedure scheduled at UWHC at
9:00 a.m. You are not to eat or drink for twelve hours prior to the
ii. "This is UHWC calling to tell you your procedure that was scheduled for
tomorrow is cancelled. Please call (number) to reschedule."
c. The following information should never be left on an answering
machine/voicemail unless the patient has given staff permission to do so:
i. Name of clinic or department
ii. Lab or other diagnostic results
iii. Any other information that would suggest a diagnosis
Exception: If it is necessary to leave the name of the clinic or the
department to prevent a "no-show" or because the patient has more than
one clinic visit scheduled in proximity to each other.
B. Patient's Request for Alternative Communications
1. All requests for alternative communications must be directed to Assisted Scheduling,
Clinic Registration, UWHC's Inpatient Admission, or Patient Accounting
staff. Individuals requesting alternative communications will be informed that if they
make such a request, all future communications initiated by UWHC will be made in that
manner. UWHC will not accept requests for no communications.
Exception: If it is necessary to communicate urgently with the patient or the patient's
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legally authorized representative (e.g. to convey a positive blood culture), staff may use
the patient or their legally authorized representative's home address or phone number, or
emergency contact information.
2. All staff and providers are responsible for taking measures to ensure that the most up to
date information is used prior to communicating with the patient, the patient's legally
authorized representative, or guarantor/insurance subscriber. An individual's request for
alternative communication will be accessible through Health Link, and will be printed on
face sheets and other documents that include printed demographic information (e.g.
Ambulatory Data Sheet).
Sr. Management Sponsor: SVP, General Counsel
Author: Compliance and UW Health Privacy Officer
Approval Committee: Administrative Policy and Procedure Committee
President, University of Wisconsin Hospitals
Chief of Clinical Operations
Previous revision: December 2012
Next revision: December 2018