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.
What is your medical information? All the health care related information we have in your file, including your medical history, current condition, diagnosis, examination notes, test results, X-rays and prescriptions.
Why are you getting this Notice? We must comply with the HIPAA Privacy Rule that requires us to protect the confidentiality of your medical information. The Privacy Rule also gives you certain rights with respect to your medical information. This Notice explains both our obligations and your rights under the Privacy Rule.
- Our Obligations
- We have a legal duty to protect the confidentiality of your health information. We are required to protect the confidentiality of your individually identifiable health information (“protected health information” or “PHI”). We must give you notice of our legal duties and privacy practices concerning your PHI:
- We must protect PHI that we have created or received about your past, present, or future health condition, health care we provide to you, or payment for your health care.
- We must notify you about how we will protect your PHI.
- We must explain how, when and why we will use and/or disclose your PHI.
- We may only use and/or disclose PHI as we have described in this Notice.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:
- Posting the revised Notice in our offices;
- Making copies of the revised Notice available upon request (either at our offices or through the contact person listed in this Notice); and
- Posting the revised Notice on our website.
We may legally use and disclose your PHI as follows:
- We may use and disclose PHI about you to provide health care treatment to you. We may use and disclose PHI about you to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another health care provider.
- We may use and disclose PHI about you to obtain payment for services. Generally, we may use and give your medical information to others to collect payment for the treatment and services provided to you. For example, we may also share portions of your medical information with the following:
- Collection departments or agencies;
- Hospital departments that review the care you received to check that it and the costs associated with it were appropriate for your illness or injury; and
- Consumer reporting agencies (e.g., credit bureaus).
- We may use and disclose your PHI for our internal health care operations. We may use and disclose PHI in performing business activities, which we call “health care operations”. These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. Examples of the way we may use or disclose PHI about you for “health care operations” include the following:
- Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients. For example, we may use PHI about you to develop ways to assist our health care providers and staff in deciding what medical treatment should be provided to others.
- Improving health care and lowering costs for groups of people who have similar health problems and to help manage and coordinate the care for these groups of We may use PHI to identify groups of people with similar health problems to give them information, for instance, about treatment alternatives, classes, or new procedures.
- Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.
- Providing training programs for students, trainees, health care providers or non- health care professionals (for example, physician affiliates and their office staff) to help them practice or improve their skills.
- Cooperating with outside organizations that assess the quality of the care we and others provide. These organizations might include government agencies or accrediting bodies such as The Joint Commission.
- Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty. For example, we may use or disclose PHI so that one of our physicians may become certified as having expertise in the field of age management.
- Assisting various people who review our activities. For example, PHI may be seen by doctors reviewing the services provided to you, and by accountants, lawyers, and others who assist us in complying with applicable laws.
- Planning for our medical practice’s future operations.
- Conducting business management and general administrative activities related to our practice and the services we provide.
- Resolving grievances within our practice.
- Reviewing activities and using or disclosing PHI in the event that we sell our practice.
- Complying with this Notice and with applicable laws.
4. We may use and disclose PHI under other circumstances without your prior written authorization. We may use and/or disclose your PHI under a number of circumstances in which you do not have to consent, give authorization or otherwise be given an opportunity to agree or object. Those circumstances include:
- When the use and/or disclosure is required by law. For example, when a disclosure is required by federal, state or local law or other judicial or administrative proceeding.
- When the use and/or disclosure is necessary for public health activities. For example, we may disclose your PHI if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
- When the disclosure relates to victims of abuse, neglect or domestic violence.
- When the use and/or disclosure is for health oversight activities. For example, we may disclose your PHI to a state or federal health oversight agency which is authorized by law to oversee our operations.
- When the disclosure is for judicial and administrative proceedings. For example, we may disclose your PHI in response to an order of a court or administrative tribunal.
- When the disclosure is for law enforcement purposes. For example, we may disclose your PHI in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
- When the use and/or disclosure relates to decedents. For example, we may disclose your PHI to a coroner or medical examiner for the purposes of identifying you should you die.
- When the use and/or disclosure relates to cadaveric organ, eye or tissue donation purposes.
- When the use and/or disclosure relates to medical research. Under certain circumstances, we may disclose your PHI for medical research.
- When the use and/or disclosure is to avert a serious threat to health or safety. For example, we may disclose your PHI you to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
- When the use and/or disclosure relates to specialized government functions. For example, we may disclose your PHI if it relates to military and veterans’ activities, national security and intelligence activities, protective services for the President, and medical suitability or determinations of the Department of State.
- You can object to certain uses and disclosures. Unless you object, we may use or disclose your PHI in the following circumstances:
- We may share with a family member, relative, friend or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care. We may share with a family member, personal representative or other person responsible for your care, PHI necessary to notify such individuals of your location, general condition or death.
- We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you, if necessary in an emergency situation.
If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call our contact person listed below.
- We may contact you to provide appointment reminders. We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.
- We may contact you with information about treatment, services, products or health care providers.We may use and/or disclose PHI to manage or coordinate your healthcare. This may include telling you about treatments, services, products and/or other healthcare providers.
EXAMPLE: If you are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you.
** ANY OTHER USE OR DISCLOSURE OF YOUR PHI
REQUIRES YOUR PRIOR WRITTEN AUTHORIZATION **
Under any circumstances other than those listed above, we will ask for your prior written authorization before we use or disclose your PHI. If you sign a written authorization allowing us to disclose your PHI in a specific situation, you may later cancel your authorization in writing. If you cancel your authorization in writing, we will not disclose your PHI after we receive your cancellation, except for disclosures, which were being processed before we received your cancellation.
- YOUR RIGHTS.
- You have the right to request restrictions on uses and disclosures of PHI about you.
You have the right to request that we restrict the use and disclosure of your PHI. We are not required to agree to your requested restrictions. However, if we do agree to your request we will abide by the restrictions except under the following circumstances: emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in the previous sections of this Notice. You may request a restriction by submitting your request in writing.
- You have the right to request different ways to communicate with you. You have the right to make reasonable requests with regard to how and where we contact you about your PHI. For example, you may request that we contact you at your work address or phone number or by email. Your request must be in writing and we must accommodate reasonable requests.
- You have the right to see and copy PHI about you. You have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you. Your request must be in writing. We may charge you related copying and/or summary preparation fees. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial.
- You have the right to request amendment of your medical record. You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for requesting the amendment. We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to see and copy the record as described above. We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received your PHI and who need the amendment.
- You have the right to a listing of disclosures we have made. If you ask our contact person in writing, you have the right to receive a written list of certain of our disclosures of your PHI. You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003). We are not required to include disclosures:
- For your treatment
- For billing and collection of payment for your treatment
- For our health care operations
- Requested by you, that you authorized, or which are made to individuals involved in your care, and
- Allowed by law (for examples, please the section above).
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The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If you request a list of disclosures more than once in 12 months, we may charge you a reasonable fee.
You have the right to a copy of this Notice. You have the right to request a paper copy of this Notice at any time. We will provide a copy of this Notice no later than the date you first receive services from us (except for emergency services, and then we will provide the Notice to you as soon as possible).
III. YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES. If you think your privacy rights have been violated by us, or you want to complain to us about our privacy practices, you may contact the person listed below:
Dr. Kenneth Raskin
Wisconsin Hormone Institute
at BodyLogicMD of Milwaukee
9000 West Chester Street, Suite 210,
Milwaukee, WI 53214
You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. If you file a complaint, we will not take any action against you or change our treatment of you in any way.
Effective date of this Notice: November l, 2012 until revised or revoked.