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4410 Regent Street, Madison, WI 53705
(608) 233-9746
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.
A. 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.
B. Associated Physicians, LLP (herein referred to as AP) Responsibilities
It is your right as a patient to be informed of AP's legal duties with respect to protection of the privacy of your personal health information.
AP is required to:
• Maintain the privacy of your health information;
• Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; and
• Abide by the terms of this notice.AP reserves the right to change the terms of the Notice of Privacy practices and make the new notice provisions effective for all protected health information that it maintains. AP also reserves the right to change the terms of its notice with respect to any new laws or regulations which may be enacted.
AP will promptly revise and distribute its notice whenever AP makes a substantial change to any of its privacy practices.
AP will not use or disclose your health information without your authorization, except as described in this notice.
C. 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 AP’s payment or health care operation activities. However, AP 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.
OOur standard practice will be to contact you at the addresses and/or telephone numbers currently on file for you. Please verify this information with our staff. You have the right to request that AP communicate your health information to you by alternative means or at alternative locations. AP 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. Request for Confidential Communication forms are available on site.• 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 in submitted in writing to AP. This right may not apply to certain types of psychotherapy notes and AP 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 will be asked to make this request in writing and state the reason why your record should be changed. If AP did not create the health information you believe is incorrect or if AP disagrees with you, AP may deny your request. For example, if you believe that information in your record, such as your birth date, is incorrect, you may request that the information be amended. Forms are available on site.• Obtain an accounting of disclosures of your health information.
You have the right to an accounting of disclosures of your health information that AP has made in compliance with state and federal law. Our standard accounting of disclosures will include those disclosures permitted without your authorization as described in Section E. The accounting will describe the dates of each disclosure, a brief description of the information disclosed, and the reason for disclosure. Upon request, you may receive one accounting per year at no charge and AP may charge you a reasonable fee for each subsequent request. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. 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.
D. Uses and Disclosures for Treatment, Payment and Health Care Operations
AP is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.
AP may use or disclose your health information for treatment.
AP may use or disclose your health information in the provision, coordination, or management of your health care. AP may use your health information to provide you with an appointment reminder. An appointment reminder may be made in the form of a voicemail message, a postcard, a letter, a message left on an answering machine, and/or a message left with a person answering your telephone. Please also see Section G.Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
AP may use or disclose your health information for payment.
AP 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: AP may use or disclose your information to your insurer to obtain payment for the provision of health care services.
AP may use or disclose your health information for routine health care operations.
AP 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: AP may review your health record to determine the efficiency of the services provided to you in the emergency room.
E. Uses or Disclosures of Your Protected Health Information Permitted Without
Your Authorization
Without your written authorization, AP may use or disclose your health information for the following purposes:
As Required by Law:AP 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 the federal privacy rules and limited by the more protective requirements of state law include the following:
• Disclosures about victims of elder or child abuse;
• Disclosures for judicial and administrative proceedings; or
• Disclosures for law enforcement purposes.Public health: As required by law, AP may disclose your protected health information to the State of Wisconsin for the purpose of statutory reporting.
AP may disclose your protected health information excluding mental health, alcohol or drug abuse, or developmental disability related health information, or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury, or disability.
AP may disclose your protected health information excluding your HIV test result without your authorization to a county agency investigating child abuse.
AP may disclose your protected health information excluding mental health, alcohol or drug abuse, or developmental disability related health information, or HIV test result without your authorization to the Food and Drug Administration (FDA).
AP may disclose your HIV test result without your authorization to a person that may have sustained contact that carries a potential for transmission of HIV.
AP 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: AP may disclose health information except for an HIV test result if AP reasonably believes that an individual is a victim of child or elder abuse.
Health oversight activities: AP will not disclose HIV test results to health care oversight agencies without an authorization. AP 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: AP may disclose your protected health information in response to a court order. AP may disclose your protected health information in response to a subpoena if AP is a party to a court action, AP has received your authorization to disclose and has not complied within two business days, or AP failed to respond to a request for workers’ compensation records. AP may disclose your protected health information excluding mental health, alcohol or drug abuse, or developmental disability related health information, or HIV test result in response to a subpoena from a state or federal agency.
Law enforcement: AP may disclose your protected health information except for HIV test results to county law enforcement officials for the reporting and investigation of elder and/or child abuse. AP may disclose your protected health information except for mental health, alcohol or drug abuse, or developmental disability related health information, or HIV test results to state and federal law enforcement officials. AP may disclose mental health, alcohol or drug abuse, or developmental disability related health information for limited law enforcement purposes as required by law. AP may disclose your protected health information to a law enforcement official in response to a court order.
For activities related to death:
Coroner or Medical Examiner: AP may use or disclose your protected health information that is not an HIV test result; or information related to mental health, alcohol or drug abuse, or developmental disability to a coroner or medical examiner.
Funeral Director: AP may use or disclose your HIV test result to a funeral director.
For cadaveric organ, eye or tissue donation purposes: AP 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: AP 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: AP 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: AP may disclose protected health information excluding mental health, alcohol or drug abuse, or developmental disability related health information, or HIV test result for national security, for protection of the President, and for medical suitability determination of Armed Forces personnel to a state or federal agency. AP may disclose protected health information to limited staff of a correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.
Workers' compensation: AP may disclose protected health information reasonably related to a workers' compensation injury.
AP 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 AP to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to AP’s Privacy Officer.
F. Patient Complaint Process
If you believe your privacy rights have been violated, you may file a complaint with AP 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 AP please contact AP's Privacy Officer who will provide you with the necessary assistance.
G. PLEASE NOTE:
The Health Insurance Portability and Accountability Act of April 14, 2003, requires us to be more cautious in answering questions when you call us or when someone calls us on your behalf. Please understand that our enhanced efforts to verify your identity on the phone and our greater caution is mandated by law and is intended to protect your privacy.
Regarding billing matters, we will talk with the patient, the insurance subscriber, the individual responsible for bills (as noted on the patient registration form), the custodial parent of a patient, or the legally authorized person for paying a patient’s medical bills.
We will release health information, such as lab results or medical information, to you or those authorized by you to receive this information. In summary, we have informed you of our standard operating procedures. It is your right to request restrictions or accommodations with regard to these procedures and your responsibility to notify us in writing of any such requests. Request forms are available on site.
Questions or Concerns
If you have any questions or concerns regarding your privacy rights or the information contained in this notice, please contact our Privacy Officer:
Kimberly A. Marshall
Associated Physicians, LLP
4410 Regent Street
Madison, WI 53705
Phone: 608-233-9746
Fax: 608-236-1981
Effective Date: This Notice of Privacy Practice is
effective as of April 14, 2003.