Wisconsin Michigan Physicians/Spine Pain Diagnostics Associates
Niagara Health Center/Ozaukee Surgery Center
Superior Chiropractic & Rehabilitation
NOTICE OF PRIVACY PRACTICES
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.
The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires us to: (i) maintain the privacy of medical information provided to us; (ii) provide notice of our legal duties and privacy practices; and (iii) abide by the terms of our Notice of Privacy Practices currently in effect.
Our Duty to Safeguard Your Protected Health Information.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.
“Protected Health Information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure.
We are required to notify you of any breach of your unsecured PHI.
We are required to follow the privacy practices described in this Notice, though we reserve the right to change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time and will be posted in our reception areas. In addition, you may request a copy of the revised notice at any time
Upon your request, we will provide you with any revised Notice of Privacy Practices, by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
WHO WILL FOLLOW THIS NOTICE
This notice describes the practices of employees and staff of Wisconsin Michigan Physicians and Niagara Health Center. This notice applies to each of these individuals, entities, sites and locations. In addition, these individuals, entities, sites and locations may share medical information with each other for treatment, payment and health care operation purposes described in this notice.
INFORMATION COLLECTED ABOUT YOU
In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as:
- Your name, address, phone number, social security number, and your emergency contact information;
- Information relating to your medical history;
- Your insurance information and coverage, and
- Information concerning your doctor, nurse or other medical providers.
In addition, we will gather certain medical information about you and will create a record of the care provided to you. Some information also may be provided to us by other individuals or organizations that are part of your care such as clinical laboratories, diagnostic testing services, your other doctors, your health plan, and close friends or family members.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU
We may use and disclose personal and identifiable health information about you for a variety of purposes. All of the types of uses and disclosures of information are described below, but not every use or disclosure in a category is listed.
I. REQUIRED DISCLOSURES.
We are required to disclose health information about you to the Secretary of Health and Human Services, upon request, to determine our compliance with HIPAA and to you, in accordance with your right to access and right to receive an accounting of disclosures, as described below.
II. PERMITTED USE AND DISCLOSURE.
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with third parties that have access to your protected health information. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment. Please note that we will not disclose any mental health or HIV records without the written consent of the patient.
Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. We may also need to inform your payer of the treatment that you are going to receive in order to obtain prior approval or to determine whether the service is covered.
For Health Care Operations.
We may use and disclose information about you for the general operation of our business. For example, we sometimes arrange for accreditation organizations, auditors or other consultants to review our practices, evaluate our operations, and tell us how to improve our services. Or, for example, we may use and disclose your health information to review the quality of services provided to you.
In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
Our Business Associates:
We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
Required By Law
We may disclose health information about you when we are required to do so by federal, state, or local law. There are a number of public policy reasons why we may disclose information about you, which are described below.
We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
We may disclose protected health information to a health oversight agency for activities authorized by law. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of 1) the health care system, 2) governmental benefit programs for which health information is relevant to determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which health information is necessary for determining compliance with program standards, or 4) entities subject to civil rights laws for which health information is necessary for determining compliance.
Abuse or Neglect:
We are also permitted to disclose protected health information to a public health authority or other government authority authorized by law to receive reports of child abuse or neglect. We may disclose a patient’s health information where we reasonably believe a patient is a victim of abuse, neglect or domestic violence and the patient authorizes the disclosure or it is required or authorized by law.
Food and Drug Administration:
We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. We may also release protected health information in the absence of such an order and in response to a discovery or other lawful request, if efforts have been made to notify you or secure a protective order.
We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Coroners, Medical Examiners, Funeral Directors, and Organ Donation:
We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Military, National Security, and Intelligence Activities; and for the Protection of the President:
When the appropriate conditions apply, we may use or disclose protected health information of individuals who are armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.
We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
We may use or disclose your PHI for research purposes, but only as permitted by law.
III. USE AND DISCLOSURES WITH OPPORTUNITY TO AGREE OR OBJECT
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare:
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. For example, we may use disclose PHI to your spouse concerning the payment of a claim. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. If you do not wish us to share your PHI with your spouse or others, you may exercise your right to request a restriction on Wisconsin Michigan Physicians and Niagara Health Center’s disclosures of your PHI.
We may use or disclose your protected health information in an emergency treatment situation. If we cannot obtain your verbal agreement before using or disclosing health information because of your incapacity or an emergency treatment circumstance, we may use or disclose some or all of the protected health information if such disclosure is: (1) Consistent with your prior expressed preference if that of the is known to your physician; and (2) it is in your best interest as determined by your physician in the exercise of professional judgment.
We may use and disclose medical information to contact you as a reminder that you have an appointment or that you should schedule an appointment.
We may use and disclose your personal health information in order to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you.
IV. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITH YOUR AUTHORIZATION
We are required to obtain written authorization from you for any other uses and disclosures of medical information other than those described above, including:
- Most uses and disclosures of psychotherapy notes (if recorded by us)
- Uses and disclosures of PHI for marketing purposes, including subsidized treatment communications. For example, your name and address may be used to send you a newsletter about our practice and the service we offer. We may also send you information about products and services that we believe may be beneficial to you.
- Disclosures that constitute a sale of PHI; and,
- Other uses and disclosures not described in this Notice of Privacy Practices
Furthermore, if we intend to send fundraising communications to you, we must inform you of this intent. You have the right to opt out of such fundraising communications with each solicitation.
If you provide us with written authorization, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization, except to the extent we have already relied on your permission.
V. YOUR RIGHTS
You have the right to request a restriction of your protected health information.
This means that you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.
If you have paid for services out-of-pocket and in full, and you request that we do not disclose PHI related solely to those services to a health plan, we must comply with your request, except where we are required by law to make a disclosure. You must make such a request in writing and your request should identify the following:
· The information to be restricted
· The type of restriction being requested (i.e. on the use of information, the disclosure of information, or both)
· To whom the limits should apply
For all other situations, HIPAA does not require us to agree to your request but we will accommodate reasonable requests when appropriate. If we believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If we do agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.
We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such a termination. You also have the right to terminate, in writing or orally, any agreed-to restriction.
With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by filling out a form which will be provided to you by request. Your request must state the specific restriction requested and to whom you want the restriction to apply.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. For example, you may ask that we only contact you at work, home or by mail. Please make this request in writing to our Privacy Officer.
You have the right to inspect and copy your protected health information.
This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about you. A request for PHI must be made in writing. Access request forms are available from us.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to it. Under certain circumstances, we may deny you access to your PHI. Depending on the circumstances, a decision to deny access may be reviewable.
Please contact our Privacy Officer if you have questions about access to your medical record. If you ask for copies of this information, we may charge you a fee for copying and mailing.
You may have the right to have your physician amend your protected health information.
If you believe that information in your records is incorrect or incomplete, you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment such as when the information is accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
Amendment request forms are available from us. Please contact our Privacy Officer, Jaime Hathaway, to determine if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes disclosures you give us authorization to make. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. If you ask for this information from us more than once every twelve months, we may charge you a fee.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
To exercise any of your rights, please contact us in writing to our Privacy Officer, Jaime Hathaway, at 1601 Roosevelt Road, PO Box 6, Niagara, WI 54151.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. You may call our Privacy Officer, Jaime Hathaway, at 888-724-6377 for further information about the complaint process.
YOU WILL NOT BE RETALIATED AGAINST OR PENALIZED BY US FOR FILING A COMPLAINT.
If you have any questions about this Notice you may contact our Privacy Officer, Jaime Hathaway, at 1601 Roosevelt Road, Niagara, WI 54151.
This notice is effective as of April 14, 2003, and revised as of September 23, 2013.