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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: Uses & Disclosures of Protected Health Information for Fundraising
Policy Number: 6.34
Effective Date: June 1, 2015
Chapter: Medical Records
To provide guidance on the proper procedures to follow when using and disclosing protected health
information ("PHI") for fundraising purposes. This policy does not address uses and disclosures of PHI
for purposes of marketing. Please see Hospital Administrative Policy 6.23-Uses and Disclosures of
Protected Health Information for Marketing Purposes for more information.
UWHC will follow state and federal laws regarding procedures for fundraising.
A. Protected Health Information (“PHI”) is defined as individually identifiable health information
that is transmitted, or maintained in any form, including oral, written, or electronic.
B. Fundraising means appeals for money, sponsorship of events, etc. Fundraising does not include
royalties or remittances for the sale of products of third parties (except auctions, rummage sales
C. Demographic information means name, address, and other contact information such as age,
gender, and insurance status.
D. Legally authorized representative means a person with authority under state law or hospital policy
to act on behalf of the patient. For example, a parent, guardian, spouse, or power of attorney.
E. Institutionally related foundation means a foundation that qualifies as a nonprofit charitable
foundation under section 501(c)(3) of the Internal Revenue Code and that has in its charter
statement of charitable purposes an explicit linkage to the covered entity. The University of
Wisconsin Foundation and Alumni Association (“UWFAA”) is an institutionally related
fundraising foundation for and Business Associate of UWHC and UW-Madison. Friends of
University of Wisconsin Hospital and Clinics Inc. ("Friends") is also an institutionally related
foundation that fundraises on behalf of UWHC.
A. UW Health Marketing and Public Affairs Role in UWHC's Fundraising Efforts
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1. All fundraising communications, regardless of whether they need an authorization or not
(see below) must be reviewed and approved by UW Health Marketing and Public Affairs.
As necessary, UW Health Marketing and Public Affairs will with work with UWFAA
and/or Friends for fundraising efforts.
2. All UWHC fundraising communications that are sent to UWHC patients must include a
description of how the individual may opt out of receiving further fundraising materials.
UW Health Marketing and Public Affairs, the UWFAA and/or Friends staff shall make
reasonable efforts to ensure that individuals who choose to opt out do not receive future
3. If written authorization is required for fundraising purposes (see below), UW Health
Marketing and Public Affairs, Friends, and/or UWFAA must work with UWHC's
Compliance & Privacy Officer to develop a communication that contains the required
elements for obtaining valid authorization for fund-raising purposes. Acknowledged
authorizations will be maintained by UW Health Marketing and Public Affairs and/or
B. Requirements for Uses and/or Disclosures of PHI for Fundraising. Any use and/or disclosure of
PHI for fundraising purposes must be reviewed and approved by: (a) the Vice President of UW
Health Marketing and Public Affairs (or his/her designee); and (b) the UWHC Compliance &
Privacy Officer (or his/her designee).
C. Fundraising on Behalf of Third Parties
UWHC will not provide mailing lists directly to third parties for their marketing or fundraising
Sr. Management Sponsor: SVP, & General Counsel
Author: Compliance & Privacy Officer
Approval Committee: Administrative Policy & Procedure Committee
President & CEO
Previous revision: 032012
Next revision: 062018