Notice of Privacy Practices
Purpose: This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices. This form, Notice of Privacy Practices, requires customization to match the particular privacy practices of the various services we offer, as well as the various relationships we have with others.
Instructions: Consult our Privacy Official and legal counsel to ensure that the Notice of Privacy Practices we intend to use accurately reflects our privacy practices. This Notice reflects the greater privacy protections and rights afforded by the Wisconsin patient confidentiality statute. We must check other applicable state privacy law to determine if it provides greater privacy protections or rights than federal law. If so, our Notice must reflect those greater protections or rights. Our Privacy Official must approve each Notice of Privacy Practices to ensure that the Notice sufficiently complies with applicable federal and state laws before we may distribute the Notice.
We must distribute this Notice to each individual no later than the date of our first service delivery, including service delivered electronically after April 14th 2003. We must also have the Notice available at the service delivery site for individuals to request to take with them. We must post the Notice at each of our physical service delivery sites in a clear and prominent location where it is reasonable to expect any individuals seeking service from us to be able to read the Notice. Whenever the Notice is revised, we must make the Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the Notice to each new patient at the time of service delivery and to any person requesting a Notice.
We must make a good faith effort to obtain a written acknowledgment of receipt of this Notice from each individual with whom we have a direct treatment relationship and to whom we provide this Notice, except in emergency situations. If we do not obtain the acknowledgement, we must document our efforts and the reason we did not obtain the acknowledgement.
Four Winds Manor
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 OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US
Applicable federal and state law require Four Winds Manor to maintain the privacy of your medical information. You are entitled to this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect September 23rd 2013 and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.
For more information about out privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
Uses and Disclosures of Medical Information
We may use and disclose medical information about you for treatment, payment, and health care operations. These terms are described below.
Treatment: We may use or disclose your medical information to provide, coordinate, or manage your health care and related services by both our practice and other health care providers providing treatment to you. We may consult with other health care providers concerning you and as part of the consultation share your medical information with them. Similarly, we may refer you to another health care provider and as part of the referral, share medical information about you with that provider.
Payment: We may use and disclose your medical information so that we may be paid for services provided to you. For example, we may need to give your insurance company, or other third-party payor, information about the health care services we provide you so that the insurance company will pay us for those services or reimburse you for amounts you have paid.
Health Care Operations: We may use and disclose your medical information in connection with our health care operations. For example, we may use your information to determine the quality of care you have received, business planning and compliance with the law.
We may also use your information for the following purpose:
How Four Winds Manor May Use or Disclose Your Health Information
The following categories describe the ways that Four Winds Manor may use and disclose your health information without your authorization.
1. Required by Law. We may use and disclose your health information when that use or disclosure is required by law. For example, we may disclose medical information to submit required reports to state or federal officials.
2. Public Health. We may release your health information to local, state or federal public health agencies, for example for reporting communicable diseases, aiding in the prevention or control of certain diseases and reporting problems with products and reactions to medications to the Food and Drug Administration.
3. Victims of Abuse, Neglect or Violence. We may disclose your information to a government authority authorized by law to receive reports of abuse, neglect or other mistreatment.
4. Health Oversight Activities. We may disclose your health information to health agencies authorized by law to conduct audits, investigations, inspections, licensure and other proceedings related to oversight and compliance.
5. Judicial and Administrative Proceedings. We may disclose your health information in the course of an administrative or judicial proceeding in response to a court order.
6. Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purpose.
7. Coroners and Medical Examiners. We may disclose your health information to coroners and medical examiners. For example, this may be necessary to determine the cause of death.
8. Research. Under certain circumstances, and only after a special approval process for authorized research, we may use and disclose your health information to help conduct medical research.
9. To Avert a Serious Threat to Health of Safety. We may disclose your health information in a very limited manner to appropriate persons to prevent a serious threat to the health or safety of a particular person or the general public. Such disclosure is usually limited to law enforcement personnel who are involved in protecting the public safety.
10. Specialized Government Functions. Under certain and very limited circumstances, we may disclose your health care information for military, national security, or law enforcement custodial situations.
11. Workers’ Compensation. Both state and federal law allow the disclosure of your health care information that is reasonably related to a worker’s compensation injury to be disclosed without your authorization.
12. Treatment Alternatives or Other Health-Related Benefits and Services. We may use and disclose medical information about you to contact you about treatment alternatives and, health-related benefits and services, that may be of interest to you. With your written permission, we may disclose your medical information to a business associate to assist us in these activities.
We may use or disclose your medical information to encourage you to purchase or use a product or service by face-to-face communication or to provide you with promotional gifts.
All other use and disclosure of medical information about you to make a communication about a product or service to encourage the purchase of a product or service will be done only upon your written authorization.
13. Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your unsecured health information.
14. Four Winds Manor Directory. Unless you object, we may use your health information, such as your name, location in our facility, your general health condition and your religious affiliation for our facility directory. It is our duty to give you enough information so you can decide whether or not to object to release of this information for our directory.
If you do not object and the situation is not an emergency, and disclosure is not otherwise prohibited by law, we are permitted to release your information under the following circumstances;
a. To individuals involved in your care-we may release your health information to a family member, other relative, friend or other person whom you have identified to be involved in your health care or the payment of your health care;
b. To family-we may use your health information to notify a family member, a personal representative or a person responsible for your care, of your location, general condition, or death; and
c. To disaster relief agencies-we may release your health information to an agency authorized by law to assist in disaster relief activities.
On Your Authorization:
Uses and Disclosures not described in this Notice will be made only with the individual’s written authorization. Uses and disclosures of any protected health information for marketing purposes and disclosures that constitute the sale of such information requires an authorization. In the event we intend to use your information for purpose of fundraising, you will have the right to opt out of receiving such communications. You may give us a written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your medical information for any reason except those described in this notice.
Your Individual Rights With Respect to Your Medical Information
Access: You have the right to inspect or receive copies of your medical information, with limited exceptions. You have the right to request that the copy be in an electronic form or format. If that form and format are not readily producible, we will work with you to provide it in a reasonable electronic form or format. This right of access does not apply to psychotherapy notes, which are maintained for the personal use of a mental health professional. You must make a request in writing to obtain access to your medical information using a form available from the contact person listed at the end of this notice. You may also request access sending us a letter to the address at the end of this notice. We may charge you a reasonable fee to cover our expenses when copying or transmitting your health information at your request.
Mobile Device: You have the right to personally take photos of protected health information with mobile devices. However if you so choose, the photos will no longer be covered by the Federal Privacy Standards.
Confidential Communication: You have the right to request that we communicate with you about your medical information by certain means or certain locations. For example, you can ask that we only contact you by mail or at work. If you wish to request such alternative communication, please contact the person listed at the end of this notice to obtain the form for such request. We must accommodate your request if it is reasonable, we may, however, require information from you that provides satisfactory explanation how payments will be handled under the alternative means or location you request.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclose your medical information for purpose, other than treatment, payment, health care operations for which we have written permission, as authorized by you, and for and certain activities, since April 14, 2013. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your medical information, a description of the medical information we disclosed, the reason for the disclosure, and certain other information.
If you request a disclosure accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional request. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your medical information. Such request must be made in writing, a form for such request is available from the contact person found at the end of this notice. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is documented in writing.
You may restrict request restrictions on your personal health information disclosures to your health plan for those health services or items you have paid privately/out-of-pocket in full (Medicare and Medicaid are not “health plans” for purpose of this section). We must comply with such request.
Amendment. You have the right to request that we amend your medical information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable affects to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.
Notified of a Breach: We are required by law to maintain the privacy of protected health information, to provide you with this notice or our legal duties and privacy practices with respect to protected health information, and to notify you following a breach of your unsecured protected health information.
Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain this notice in written form.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed below.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health & Human Services.
Telephone: ___________________________ Fax: ______________________________