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.
Your Health Care Information -- Protecting Your Privacy
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.
Pediatrics West's Responsibilities
It is your right as a patient to be informed of Pediatrics West's legal duties with respect to protection of the privacy of your personal health information.
Pediatrics West is required to:
Pediatrics West will promptly revise and distribute its notice whenever Pediatrics West makes a substantial change to any of its privacy practices.
Pediatrics West will not use or disclose your health information without your authorization, except as described in this notice.
Your Health Information Rights
You have the right to:
Pediatrics West is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.
Pediatrics West may use or disclose your health information for treatment.
Pediatrics West may use or disclose your health information in the provision, coordination or management of your health care.
Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
Example: Pediatrics West may use your health information to provide you with an appointment reminder.
Example: Pediatrics West may send you information about treatment alternatives or other health related services that may be of interest to you.
Pediatrics West may use or disclose your health information for payment.
Pediatrics West may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis, and your treatment.
Example: Pediatrics West may use or disclose your information to your insurer to obtain payment for the provision of health care services.
Pediatrics West may use or disclose your health information for routine health care operations.
Pediatrics West may use or disclose your health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.
Example: Pediatrics West may review your health record to determine the efficiency of the services provided to you in the emergency room.
Example: Pediatrics West may contact you as part of a fundraising activity sponsored by your health care provider.
Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization.
Without your written authorization, Pediatrics West may use or disclose your health information for the following purposes:
As Required by Law: Pediatrics West may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:
Pediatrics West may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.
Pediatrics West may disclose your protected health information excluding your HIV test result without your authorization to a county agency investigating child abuse.
Pediatrics West may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result without your authorization to the Food and Drug Administration (FDA).
Pediatrics West may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.
Pediatrics West may disclose your protected health information that is reasonably related to a work related illness or injury if an application for workers compensation has been filed.
Victims of abuse, neglect or domestic violence: Pediatrics West may disclose health information except for an HIV test result if Pediatrics West reasonably believes that an individual is a victim of child or elderly abuse.
Health oversight activities: Pediatrics West will not disclose HIV test results to health care oversight agencies without an authorization. Pediatrics West may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your protected health information may be disclosed without your authorization to a state or federal agency.
Judicial and Administrative Proceedings: Pediatrics West may disclose your protected health information in response to a court order. Pediatrics West may disclose your protected health information in response to a subpoena if Pediatrics West is a party to a court action, Pediatrics West has received your authorization to disclose and has not complied within two business days or Pediatrics West has failed to respond to a request for workers' compensation records. Pediatrics West may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result in response to a subpoena from a state or federal agency.
Law enforcement: Pediatrics West may disclose your protected health information except for HIV test results to county Law enforcement officials for the reporting and investigation of elderly and/or child abuse. Pediatrics West may disclose your protected health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results to state and federal law enforcement officials. Pediatrics West may disclose mental health, alcohol, or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. Pediatrics West may disclose your protected health information to a law enforcement official in response to a court order.
For activities related to death: Corner or Medical Examiner: Pediatrics West may use or disclose your protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse and developmental disabilities to a coroner or medical examiner.
Funeral Director: Pediatrics West may use or disclose your HIV test result to a funeral director.
For cadaveric organ, eye or tissue donation purposes: Pediatrics West may use or disclose your HIV test result to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.
Research: Pediatrics West may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.
To avoid a serious threat to health or safety: Pediatrics West may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.
Disclosures for specialized government functions: Pediatrics West may disclose protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result for national security, for protection of the President and for medical suitability determination or of Armed Forces personnel to a state or federal agency.
Pediatrics West may disclose protected health information to funded staff or correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.
Workers compensation: Pediatrics West may disclose your protected health information reasonably related to workers' compensation injury.
Pediatrics West has attempted to explain with this notice the circumstances where state law may be more protective than the federal privacy rule and provides greater privacy protection.
Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your health information requires Pediatrics West to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to Pediatrics West Privacy Officer.
Patient Complaint Process
If you believe your privacy rights have been violated you may file a complaint with Pediatrics West or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint. To file a complaint with Pediatrics West please contact the Pediatrics West Privacy Officer who will provide you with the necessary assistance.
Questions or Concerns
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:
Pediatrics West
Lorelle M. Manion M.D.
Megan E. G. Hambrook M.D.
1305 North Barker Rd.
Suite 1
Brookfield, WI 53045
262-784-3200
Effective Date: This Privacy Practice is effective as of April 14th 2003.
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.
Pediatrics West's Responsibilities
It is your right as a patient to be informed of Pediatrics West's legal duties with respect to protection of the privacy of your personal health information.
Pediatrics West is required to:
- Maintain the privacy of your health information;
- Provide you with a notice of the legal duties and practices regarding protected health information collected and maintained about you; and
- Abide by the terms of this notice.
Pediatrics West will promptly revise and distribute its notice whenever Pediatrics West makes a substantial change to any of its privacy practices.
Pediatrics West will not use or disclose your health information without your authorization, except as described in this notice.
Your Health Information Rights
You have the right to:
- Request a restriction on certain uses and disclosures of your health information. You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or Pediatrics West payment or health care operation activities. However, Pediatrics West is not required to agree to your requested restriction. For example, if you are an employee of the clinic and you receive health care services in the clinic, you may request that your health care record not be maintained in the general record filing area.
- Receive Confidential Communications. You have the right to request that Pediatrics West communicate your health information to you by alternative means or at alternative locations. Pediatrics West shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record.
- Inspect and obtain a copy of your health record. You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be submitted in writing to Privacy Officer. This right may not apply to certain types of psychotherapy notes and Pediatrics West may charge you a reasonable fee for a copy of your health care record. For example, you may request a copy of your health care record from your family physician.
- Amend your health record. You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health record should be changed. If Pediatrics West did not create the health information you believe is incorrect or if Pediatrics West disagrees with you, Pediatrics West may deny your request. For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended.
- Obtain an accounting of disclosures of your health information. You have the right to an accounting of disclosures of your health information that Pediatrics West has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. You will receive one accounting per year at no charge and Pediatrics West may charge you a reasonable fee for each subsequent request. For example, you may request an accounting of disclosures made from your health record in the last year to the State for disease reporting.
- Obtain a paper copy of the notice upon request. You have the right to obtain a paper copy of the notice upon request. For example, if you have received the notice electronically, you may request that Pediatrics West provide a paper copy of the notice.
Pediatrics West is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.
Pediatrics West may use or disclose your health information for treatment.
Pediatrics West may use or disclose your health information in the provision, coordination or management of your health care.
Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
Example: Pediatrics West may use your health information to provide you with an appointment reminder.
Example: Pediatrics West may send you information about treatment alternatives or other health related services that may be of interest to you.
Pediatrics West may use or disclose your health information for payment.
Pediatrics West may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis, and your treatment.
Example: Pediatrics West may use or disclose your information to your insurer to obtain payment for the provision of health care services.
Pediatrics West may use or disclose your health information for routine health care operations.
Pediatrics West may use or disclose your health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.
Example: Pediatrics West may review your health record to determine the efficiency of the services provided to you in the emergency room.
Example: Pediatrics West may contact you as part of a fundraising activity sponsored by your health care provider.
Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization.
Without your written authorization, Pediatrics West may use or disclose your health information for the following purposes:
As Required by Law: Pediatrics West may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:
- Disclosures about victims of elderly or child abuse
- Disclosures for judicial and administrative proceedings; or
- Disclosures for law enforcement purposes.
Pediatrics West may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.
Pediatrics West may disclose your protected health information excluding your HIV test result without your authorization to a county agency investigating child abuse.
Pediatrics West may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result without your authorization to the Food and Drug Administration (FDA).
Pediatrics West may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.
Pediatrics West may disclose your protected health information that is reasonably related to a work related illness or injury if an application for workers compensation has been filed.
Victims of abuse, neglect or domestic violence: Pediatrics West may disclose health information except for an HIV test result if Pediatrics West reasonably believes that an individual is a victim of child or elderly abuse.
Health oversight activities: Pediatrics West will not disclose HIV test results to health care oversight agencies without an authorization. Pediatrics West may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your protected health information may be disclosed without your authorization to a state or federal agency.
Judicial and Administrative Proceedings: Pediatrics West may disclose your protected health information in response to a court order. Pediatrics West may disclose your protected health information in response to a subpoena if Pediatrics West is a party to a court action, Pediatrics West has received your authorization to disclose and has not complied within two business days or Pediatrics West has failed to respond to a request for workers' compensation records. Pediatrics West may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result in response to a subpoena from a state or federal agency.
Law enforcement: Pediatrics West may disclose your protected health information except for HIV test results to county Law enforcement officials for the reporting and investigation of elderly and/or child abuse. Pediatrics West may disclose your protected health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results to state and federal law enforcement officials. Pediatrics West may disclose mental health, alcohol, or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. Pediatrics West may disclose your protected health information to a law enforcement official in response to a court order.
For activities related to death: Corner or Medical Examiner: Pediatrics West may use or disclose your protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse and developmental disabilities to a coroner or medical examiner.
Funeral Director: Pediatrics West may use or disclose your HIV test result to a funeral director.
For cadaveric organ, eye or tissue donation purposes: Pediatrics West may use or disclose your HIV test result to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.
Research: Pediatrics West may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.
To avoid a serious threat to health or safety: Pediatrics West may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.
Disclosures for specialized government functions: Pediatrics West may disclose protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result for national security, for protection of the President and for medical suitability determination or of Armed Forces personnel to a state or federal agency.
Pediatrics West may disclose protected health information to funded staff or correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.
Workers compensation: Pediatrics West may disclose your protected health information reasonably related to workers' compensation injury.
Pediatrics West has attempted to explain with this notice the circumstances where state law may be more protective than the federal privacy rule and provides greater privacy protection.
Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your health information requires Pediatrics West to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to Pediatrics West Privacy Officer.
Patient Complaint Process
If you believe your privacy rights have been violated you may file a complaint with Pediatrics West or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint. To file a complaint with Pediatrics West please contact the Pediatrics West Privacy Officer who will provide you with the necessary assistance.
Questions or Concerns
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:
Pediatrics West
Lorelle M. Manion M.D.
Megan E. G. Hambrook M.D.
1305 North Barker Rd.
Suite 1
Brookfield, WI 53045
262-784-3200
Effective Date: This Privacy Practice is effective as of April 14th 2003.
