Designation of the University of Wisconsin Affiliated Covered Entity (UW ACE)

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Policy Number:
UW-101
Old Policy Number:
1.2
Responsible Office:
Office of Compliance

University Policy

Rationale/​Purpose:

This policy describes the components of the UW-Madison Affiliated Covered Entity (UW ACE) as it relates to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. The HIPAA Privacy Rule governs how organizations handle protected health information (PHI). HIPAA regulations apply to businesses and individuals in the health care industry such as health plans and health care providers. These are called “covered entities,” meaning they are “covered” by HIPAA. An affiliated covered entity (ACE) is formed when two or more legally separate covered entities have an affiliation (meaning they are under common ownership or control) and designate themselves as a single covered entity for purposes of complying with HIPAA.

Definitions:
Affiliated covered entity (ACE)
Legally separate covered entities connected through common ownership or control that choose to act as a single covered entity for purposes of following HIPAA rules.
Covered entity
A health plan, health care clearinghouse, or health care provider that sends any health information in electronic form in connection with a transaction covered by HIPAA.
Health care component (HCC)
A unit or combination of units of a hybrid entity designated by the hybrid entity as covered by HIPAA.
Hybrid entity
A single legal entity that meets the definition of a covered entity under HIPAA, but whose business activities include both covered and non-covered functions, and that designates a health care component.
UW–Madison health care component (UW HCC)
Those units of UW–Madison that have been designated by the university as part of its health care component under HIPAA. See UW-100 Designation of the UW–Madison Health Care Component (UW HCC) for a listing of these units.
Scope:

Applies to UW-Madison students, staff, and affiliates who are within the UW Health Care Component, UW Affiliated Covered Entity, or otherwise access protected health information

Policy:
  1. The UW Affiliated Covered Entity (ACE) is made up of the following entities:
    1. The units of the UW HCC, except for University Health Services, the State Laboratory of Hygiene, and the Athletics Department.
    2. The University of Wisconsin Hospitals and Clinics Authority.
    3. The University of Wisconsin Medical Foundation, Inc.
    4. SwedishAmerican Hospital, including SwedishAmerican Medical Group, SwedishAmerican Home Health Care, and SwedishAmerican Medical Center Belvidere.
    5. Chartwell-Midwest Wisconsin, LLC and Chartwell-Midwest Wisconsin Health Resources, LLC.
  2. The UW ACE is documented by the members of the UW ACE in an Affiliated Covered Entity Designation Agreement.
Related UW-Madison Policies:
Related UW–Madison Documents, Web Pages, or Other Resources:
External References:

45 C.F.R. § 164.105

Policy Administration

Approval Authority:
Vice Chancellor for Legal Affairs
Policy Manager:
HIPAA Privacy Officer
Contact:
HIPAA Privacy Officer -- Jack Talaska, JACK.TALASKA@WISC.EDU, (608) 265-4077
Effective Date:
04-14-2003
Revised Dates:

05-26-2014: Effective date of the revised policy: 05-26-2014.
07-12-2018: Effective date of the revised policy: 07-12-2018.
11-22-2019: Effective date of the revised policy: 11-22-2019.
03-26-2020: Effective date of the revised policy: 03-26-2020.
05-11-2025: Effective date of the revised policy: 05-11-2025.

Retrieved:
05-18-2025 17:56:56