University of Wisconsin Medical Foundation
Policy Name: Marketing Use of Protected
Health Information Policy
Policy Number: Privacy 011
X New ____ Revised
If Revised, Supersedes Policy Dated: ______
Effective Date: April 14, 2003
Approved By (Name): Peter Christman Title: Executive Vice President
The University of Wisconsin Medical Foundation (“UWMF”) maintains the privacy and
confidentiality of patients’ Protected Health Information (“PHI”). The purpose of this policy is
to advise UWMF staff that the UWMF Marketing Department coordinates all UWMF marketing
and communication initiatives, and to outline the manner in which PHI may and may not be used
by UW Health for marketing activities, in compliance with both federal and state law and
Marketing Activity means a communication which encourages the recipient to purchase or to
use a product or service, unless the communication is made:
To describe the inclusion of UW Faculty Physicians and /or UWMF facilities in a network of
providers incident to a health benefit plan;
For treatment of the patient;
Case management or care coordination for a patient; or
To direct a patient to alternative recommended treatments, therapies, health care providers, or
A communication is a Marketing Activity if the UWMF shares a patient’s PHI with another
person or company, in exchange for direct or indirect payment or benefit, in order that the other
person or company may use such information to send a communication which encourages
recipients to purchase that person’s or company’s products or services.
UWMF engages in marketing activities which are designed to protect the privacy of its patients’
PHI. A patient’s PHI may not be used for Marketing Activities unless either a valid, written
Authorization has been obtained from the patient or the Marketing Activity falls within an
exception outlined in Section IV.B., below.
A. Authorization. The use of an Authorization form is required for all Marketing
Activities, unless the Marketing Activity falls within an exception specified in Section IV.B.,
below. Please see the UWMF “Authorization for Use” and the “Authorization for
1. Authorization for Use - UWMF Marketing Purposes. A valid, written
Authorization for Use of PHI is obtained for a UWMF Marketing Activity if the activity
does not fall within the list of exceptions outlined in Paragraph IV.B., below. The
Authorization is obtained in accordance with the instructions contained on the reverse
side of the Authorization for Use form. The patient is given a complete copy of the fully
executed Authorization form.
2. Authorization for Disclosure – UWMF Release to Third Party. A valid, written
Authorization for Disclosure of PHI is obtained prior to situation where the UWMF:
i. Shares information for a third party’s Marketing Activity;
ii. Collaborates with a third party to provide PHI for a joint Marketing Activity; or
iii. Sends a communication to facilitate the Marketing Activity of a third party’s
product or service.
The Authorization is obtained in accordance with the instructions contained on the
reverse side of the Authorization for Disclosure form. The patient is given a complete
copy of the fully executed Authorization form.
3. Authorization for Disclosure – UWMF Release to Third Party AND UWMF
Receives Direct / Indirect Remuneration. When the UWMF discloses PHI for a
Marketing Activity with a third party and receives direct or indirect remuneration for
such an arrangement, the arrangement and the remuneration received is specifically
disclosed to the patient on the Authorization form.
B. Exceptions – Authorization Not Required. There are certain communications which
are not considered to be a Marketing Activity or which are exempted from the Marketing
Activity requirement for patient authorization before the information is used or disclosed.
These types of communications do not require the use of an Authorization form, and are
outlined in the subparagraphs below, as follows:
1. Patient. A face to face communication with the patient;
2. Treatment. Communications which are necessary for or to facilitate the treatment of
3. Care Management. Communications which are necessary for case management or
care coordination for a patient, or which direct or recommend to the patient
alternative treatments, therapies, health care providers or settings of care;
4. Descriptions of Network Participation. Communications which describe the
inclusion of UW Faculty Physicians and /or UWMF facilities in a network of
providers incident to UWMF participation in health benefit plan provider network.
5. Our Health Related Products / Services. Communications which describe UW
Health health-related products and services to UW Health patients;
6. Free Health Related Services / Benefits. Communications regarding free health
related services available to UW Health patients; and
7. Small Promotional Gifts. A promotional gift of nominal value (for example, pens,
calendars, holiday cards, kitchen magnets, etc.).
C. Examples of Marketing Communications Which Do Not Require Patient
Authorization. The following communications are examples of communications which
1. Treatment. A communication which is necessary for the treatment of the patient.
This may include a communication which advises a patient of the need for physical
therapy treatment and where that therapy treatment might be obtained.
2. Care Management. A communication which is necessary for case management or
care coordination for a patient. This type of communication may include sending a
letter to a patient regarding a referral to another UW Health specialist.
3. Descriptions of Network Participation. A communication necessary in order to
inform the patient of alternative treatments, therapies, health care providers or
settings of care. This type of communication might include an insurer’s network
directory of participating providers or a directory of UW Health physicians and/or
4. Free Health Related Services. Communication regarding free health related
services available to a patient, such as those which promote a health fair with free
health screening activities that is available to all UWMF clinic patients.
5. Small Promotional Gifts. Promotional gifts of nominal value might include sending
a holiday card with a calendar.
D. Coordination of Marketing Activities. The UWMF Marketing Department coordinates
all UWMF marketing and communication initiatives. Any and all requests for a patient’s
PHI, or data pulls of patient(s)’ demographic information for use or disclosure relative to
a Marketing Activity are made to the Clinic Marketing Manager in the UWMF Marketing
Department. A patient's written Authorization shall be obtained before any use or
disclosure of his or her PHI for a Marketing Activity, unless the activity is an exception,
as defined above.
E. Business Associate Use. A patient’s written Authorization MUST be obtained before a
Business Associate uses or discloses that patient’s PHI for its own Marketing Activity.
F. Assistance. For additional assistance in determining the appropriateness of any use or
release of PHI for Marketing Activities, please consult with the following individuals:
Director of Health Information Department
Clinic Marketing Manager
Authorization Use Policy
Authorization for Use Form
Authorization for Disclosure Form
45 CFR 164.508
Ch. 146.82 Wis. Stats.
HIPAA Collaborative Of Wisconsin Policy & Procedure: “Uses & Disclosures of PHI That
Require Authorization,” December, 2002
Ministry Health Plan Draft Release & Disclosure of PHI Policy
VI. Author & Review
Sponsor: HIPAA Steering Committee
Author: Claudia Jane Sanders
Review: Clinic Ops Privacy Work Group
HIPAA Steering Committee
Committee Approval: Clinic Ops Privacy Work Group HIPAA Steering Committee
Senior Management Team
Approval: Peter Christman Date: April 14, 2003