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.
Your health information is personal, and we are committed to protecting
it. Your health information
is also very important to our ability to provide you with quality care,
and to comply with certain laws. This Notice applies to all records about your care that occurs
at our facility. (Your physician
may have different policies and a different notice regarding your health
information that is created in the physician’s office.)
Are Legally Required to Safeguard Your Protected Health Information.
are required by law to:
the privacy of your health information, also known as “protected health
information” or “PHI;”
you with this Notice, and
with this Notice.
Changes to Our Practices and This Notice.
reserve the right to change our privacy practices and to make any such
change applicable to the PHI we obtained about you before the change. If a change in our practices is material, we will revise this Notice
to reflect the change. You
may obtain a copy of any revised Notice by contacting the privacy Officer
at 1000 No. 92nd Street, Milwaukee, WI 53213. We will also
make any revised Notice available in our reception area and program handbook.
We May Use and Disclose Your Protected Health Information.
law requires us to obtain your prior authorization for some uses and disclosures. In other circumstances, the law allows us to use or disclose PHI
without your authorization.
and Disclosures that do not Require Your Authorization. We may use or disclose your PHI to provide treatment/services
to you or in order for others to provide treatment/services to you. For example, we may disclose your PHI to health care personnel
who are involved in your care. We may also use and disclose your PHI to contact you as a reminder
that you have an appointment for treatment/services at our facility,
to tell you about or recommend possible treatment/service options or
alternatives, or about health-related benefits or services that may
may also use or disclose your PHI to your insurance carrier in order to get paid for treatment/services provided to you. For example, we may use your PHI to create the bills that we
submit to the insurance company, or we may disclose certain portions
of your PHI to our business associates who perform billing and claims
processing or other services for us. We may also disclose your PHI to
another health care provider or insurance company for their payment-related
activities, such as to get paid for treatment/services provided to you
or to process claims under your health insurance plan.
may also use or disclose your PHI for our operations related to health
care. For example, we may use your PHI to evaluate the quality of care
you received from us, or to evaluate the performance of those involved
with your care. We may
also provide your PHI to our attorneys, accountants and other consultants
to make sure we are complying with the laws that affect us. We may also provide your contact information (such as name, address
and phone number) and the dates you received services from us to a foundation
that helps us with our fundraising efforts. In addition, we may also disclose your PHI to another health
care provider, health insurance plan or health care clearinghouse for
purposes of their operations related to health care. However, we will only do so if they have or have had a relationship
with you and if the PHI they request pertains to that relationship. In addition, we will disclose your PHI to these third parties
for limited purposes only, such as for them to conduct quality improvement
activities, or to review the performance of a health care provider,
or for training purposes.
and Disclosures That Require Us to Give You the Opportunity to Object. Unless you object, we may provide relevant portions of your
PHI to a family member, friend or other person you indicate is involved
in your health care or in helping you get payment for your health care. We may use or disclosure your PHI to notify your family or personal
representative of your location or condition. In an emergency or when you are not capable of agreeing or objecting
to these disclosures, we will disclose PHI as we determine is in your
best interest, but will tell you about it later, after the emergency,
and give you the opportunity to object to future disclosures to family
and friends. Unless you
object, we may also disclose your PHI to persons performing disaster
Uses and Disclosures Do Not Require Your Authorization. The law allows us to disclose PHI without your authorization
in the following circumstances:
Required by Law. We disclose PHI when we are required to do so by federal,
state or local law.
Public Health Activities. For example, we disclose PHI when we report suspected child abuse,
the occurrence of certain diseases, or adverse reactions to a drug
or medical device.
Reports About Victims of Abuse, Neglect or Domestic Violence. We will disclose your PHI in these reports only if we are
required or authorized by law to do so, or if you otherwise agree.
Health Oversight Agencies. We will provide PHI as requested to government agencies who
have authority to audit or investigate our operations.
Lawsuits and Disputes. If
you are involved in a lawsuit or dispute, we may disclose your PHI
in response to a subpoena or other lawful request, but only if efforts
have been made to tell you about the request or to obtain a court
order that will protect the PHI requested.
Law Enforcement. We
may release PHI if asked to do so by a law enforcement official,
in the following circumstances:
response to a court order, subpoena, warrant, summons or similar
identify or locate a suspect, fugitive, material witness or missing
the victim of a crime if, under certain limited circumstances, we
are unable to obtain the person’s agreement;
a death we believe may be due to criminal conduct;
criminal conduct at our facility; and
emergency circumstances, to report a crime, its location or victims,
or the identity, description or location of the person who committed
Coroners, Medical Examiners and Funeral Directors. We may disclose PHI to facilitate the duties of these individuals.
Organ Procurement Organizations. We may disclose PHI to facilitate organ donation and transplantation.
Medical Research. We may disclose your PHI to medical researchers who request it for
approved medical research projects; however, with very limited exceptions
such disclosures must be cleared through a special approval process
before any PHI is disclosed to the researchers, who will be required
to safeguard the PHI they receive.
Avert a Serious Threat to Health or Safety. We
may disclose your PHI to someone who can help prevent a serious threat
to your health and safety or the health and safety of another person
or the public.
Specialized Government Functions. For
example, we may disclose your PHI to authorized federal officials
for intelligence and national security activities that are authorized
by law, or so that they may provide protective services to the President
or foreign heads of state or conduct special investigations authorized
Workers' Compensation or Similar Programs. We may provide your PHI to these programs in order for you to obtain
benefits for work-related injuries or illness.
Uses and Disclosures of Your Protected Health Information.
uses and disclosures of your PHI that are not covered by this Notice or
the laws that apply to us will be made only with your written authorization. If you give us written authorization for a use or disclosure of
your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization we will no longer use or disclosure
your PHI for the purposes specified in the written authorization, except
that we are unable to take back any disclosures we have already made with
your permission. In addition,
we can use or disclose your PHI after you have revoked your authorization
for actions we have already taken in reliance on your authorization
Rights Related to Your Protected Health Information.
have the following rights:
Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us to limit how we use and disclose
your PHI, as long as you are not asking us to limit uses and disclosures
that we are required or authorized to make to the Secretary of the Department
of Health and Human Services, or the disclosures described in Section
III, above. Any such request
must be submitted in writing to our Privacy Officer. We are not required to agree to your request. If we do agree, we will put it in writing and will abide by the
agreement except when you require emergency treatment.
Right to Choose How We Communicate With You. You have the right to ask that we send information to you at
a specific address (for example, at work rather than at home) or in
a specific manner (for example, by e-mail rather than by regular mail,
or never by telephone). We
must agree to your request as long as it would not be disruptive to
our operations to do so. You
must make any such request in writing, addressed to our Privacy Officer.
Right to See and Copy Your PHI. Except for limited circumstances, you may look at and copy your
PHI if you ask in writing to do so. Any such request must be addressed to our Client Records Department,
which will respond to your request within 30 days (or 60 days if the
extra time is needed). In
certain situations we may deny your request, but if we do, we will tell
you in writing of the reasons for the denial and explain your rights
with regard to having the denial reviewed.
you ask us to copy your PHI, we will charge you a reasonable fee for
each page. Alternatively, we may provide you with a summary or explanation
of your PHI, as long as you agree to that and to the cost, in advance.
Right to Correct or Update Your PHI. If you believe that the PHI we have about you is incomplete or
incorrect, you may ask us to amend it. Any such request must be made in writing and must be addressed
to our Client Records Department, and must tell us why you think the
amendment is appropriate. We
will not process your request if it is not in writing or does not tell
us why you think the amendment is appropriate. We will act on your request within 60 days (or 90 days if the
extra time is needed), and will inform you in writing as to whether
the amendment will be made or denied. If we agree to make the amendment, we will ask you who else you
would like us to notify of the amendment.
may deny your request if you ask us to amend information that:
not created by us, unless the person who created the information is
no longer available to make the amendment;
not part of the PHI we keep about you;
not part of the PHI that you would be allowed to see or copy; or
determined by us to be accurate and complete.
we deny the requested amendment, we will tell you in writing how to
submit a statement of disagreement or complaint, or to request inclusion
of your original amendment request in your PHI.
Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have
disclosed your PHI. The
list will not include certain disclosures, such as disclosures we have
made for treatment, payment and health care operations purposes, those
that are a byproduct of another use or disclosure permitted under our
privacy policies or by law, those made under an authorization provided
by you, those made directly to you or your family or friends, or for
disaster relief purposes. Neither
will the list include disclosures we have made for national security
purposes or to law enforcement personnel, or disclosures made before
April 14, 2003.
request for a list of disclosures must be made in writing and be addressed
to our Medical Records Department. We will respond to your request within 60 days (or 90 days
if the extra time is needed). The list we provide will include disclosures made within the
last six years unless you specify a shorter period. The first list you request within a 12-month period will be free. You will be charged our costs for providing any additional lists
within the 12-month period.
Right to Get a Paper Copy of This Notice. You have the right to request a paper copy of this Notice. You may obtain a paper copy of this Notice by contacting Privacy
Officer at 1000 N. 92nd Street, Milwaukee, WI 53226. The Notice is also available in our reception areas and in
the program handbook.
you believe your privacy rights have been violated, you may file a complaint
with us or with the Secretary of the federal Department of Health and
Human Services. To file a
complaint with us, put your compliant in writing and address it to our
Privacy Officer at 1000 N. 92nd Street, Milwaukee, WI 53226. We will not retaliate against you for filing a complaint. You may also contact our Privacy Officer if you have questions
or comments about our privacy practices.
Date: April 14, 2003