YOUR M.D.’S 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 M.D., s.c. (“Your M.D.”) is required by law to maintain the privacy of your health information, to provide to you (or your representative) this Notice of our duties and privacy practices, and to notify you (or your representative) following a breach of your unsecured health information.  Your M.D. is required to abide by the terms of our Notice as may be amended from time to time.  Your M.D. has the right to change the terms of our Notice.  Any revisions to this Notice will be effective for all health information that Your M.D. has created or maintained in the past, and for any records that Your M.D. creates or maintains in the future.  Your M.D. will post our current Notice in a prominent location in our facility, as well as on our website, www.yourmdmequon.com

USE AND DISCLOSURE OF HEALTH INFORMATION

      

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND THE PURPOSES FOR WHICH YOUR M.D. MAY USE OR DISCLOSE YOUR HEALTH INFORMATION:

To Provide Treatment.  Your M.D. may use your health information to treat you and coordinate your care within Your M.D.  For example, your physician, or other health care professionals involved in your care, may use information about your symptoms in order to prescribe appropriate medications.  Your M.D. may also disclose your health information to individuals outside Your M.D. involved in your care, including family members, pharmacists, suppliers of medical equipment, or other health care professionals.

To Obtain Payment.  Your M.D. may use or disclose your health information to bill or collect payment for services or items you receive from Your M.D.  For example, Your M.D. may provide information regarding your health care status to your health insurer so that the insurer will reimburse you.  In addition, Your M.D. may disclose your health information to another health care provider subject to Federal privacy protection laws in order for that health care provider to bill or collect payment for services or items rendered to you.    

To Conduct Health Care Operations.  Your M.D. may use your health information for our own operations in order to facilitate the function of Your M.D. and as necessary to provide quality care to all Your M.D. patients.  For example, Your M.D. may use your health information to evaluate our staff performance, combine your health information with that of other Your M.D. patients to evaluate how to more effectively serve all Your M.D. patients, disclose your health information to Your M.D. staff and contracted personnel for training purposes, or use your health information to contact you or your family as part of general community information mailings.  Your M.D. may also disclose your health information to a health oversight agency performing activities authorized by law, such as investigations or audits.  These agencies include governmental agencies that oversee the health care system, government benefit programs and organizations subject to government regulation and civil rights laws.  In addition, Your M.D. may disclose your health information to another health care provider subject to Federal privacy protection laws, as long as the provider has or has had a relationship with you and the information is for that provider’s health care operations.

To Inform You About Health Information That May Be of Interest to You.  Your M.D. may use or disclose your health information to tell you about or recommend possible options or alternatives for your care, or to inform you of other information that may be of interest to you.

Release of Information to Family or Friends.  Unless you specifically request in writing that Your M.D. not communicate with such person(s), Your M.D. may release your health information to a family member or friend who is involved in your treatment or who is helping pay for your care.

Business Associates.  Your M.D. may disclose your health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for them to provide such functions or services.  Your M.D. requires our business associates to agree in writing to protect the privacy of your health information, and to use and disclose your health information only as specified in that written agreement.

Health Information Exchanges.  Your M.D. may participate in an arrangement of health care organizations that have agreed to work with each other to facilitate access to health information that may be relevant to your care.  For example, if you are admitted on an emergency basis to a hospital that participates in the exchange and you cannot provide important information about your condition, the arrangement may allow the hospital to access the health information Your M.D. maintains about you to treat you at the hospital. 

THE FOLLOWING IS A SUMMARY OF THE OTHER CIRCUMSTANCES UNDER WHICH AND THE OTHER PURPOSES FOR WHICH YOUR M.D. MAY USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN CONSENT OR AUTHORIZATION:

When Legally Required.  Your M.D. will disclose your health information to the extent that it is required to do so by any Federal, State or local law.

When There Are Risks to Public Health.  Your M.D. may disclose your health information for the following public activities and purposes:

– To prevent or control disease, injury or disability, report disease, injury, vital events such as death, and the conduct of public health surveillance, investigations and interventions.

– To report adverse events, product defects, to track products or enable product recalls, repairs and replacements, and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.

– To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

– To an employer about an individual who is a member of the workforce, as legally required.

To Report Abuse, Neglect or Domestic Violence.  Your M.D. is allowed to notify government authorities if Your M.D. reasonably believes a patient is the victim of abuse, neglect or domestic violence.  Your M.D. will make this disclosure only when specifically required or authorized by law or when you authorize the disclosure.

To Conduct Health Oversight Activities.  As permitted or required by State law, Your M.D. may disclose your health information to a health oversight agency for activities such as audits, civil, administrative or criminal investigations, inspections, and licensure or disciplinary action.  If, however, you are the subject of a health oversight agency investigation, Your M.D. may disclose your health information only if it is directly related to your receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings.  As permitted or required by State law, Your M.D. may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order.  Under certain conditions, Your M.D. also may disclose your health information in response to a subpoena, discovery request or other lawful process. 

For Law Enforcement Purposes.  As permitted or required by State law, Your M.D. may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

To Coroners and Medical Examiners.  Your M.D. may disclose your health information to coroners and medical examiners for purposes of determining cause of death or for other duties, as authorized by law.

To Funeral Directors.  If necessary to carry out their duties, Your M.D. may disclose your health information to funeral directors prior to and in reasonable anticipation of, or following, your death, consistent with applicable law.

For Organ, Eye or Tissue Donation.  Your M.D. may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes.  Your M.D. may, under very select circumstances, use or disclose your health information for research.  Before Your M.D. discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. 

In the Event of a Serious Threat to Health or Safety.  Your M.D. may, consistent with applicable law and ethical standards of conduct, disclose your health information if Your M.D., in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety, or to the health and safety of the public.

For Specified Government Functions.  In certain circumstances, the Federal regulations authorize Your M.D. to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker’s Compensation.  Your M.D. may release your health information for worker’s compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than as stated above, Your M.D. will not use or disclose your health information other than with your written authorization.  Your authorization (or the authorization of your representative) is specifically required before Your M.D.:  (1) uses or discloses your psychotherapy notes; (2) uses your health information to make a marketing communication to you for which it receives financial remuneration from a third party, unless such communication is face-to-face or in other limited circumstances; or (3) discloses your health information in any manner that constitutes the sale of such information under the Health Insurance Portability and Accountability Act of 1996.  Also, some types of health information are particularly sensitive, and the law, with limited exceptions, may require that Your M.D. obtain your authorization to use or disclose that information.  Sensitive information may include information dealing with genetics, HIV/AIDS, mental health, developmental disabilities, and alcohol and substance abuse.  If required by law, Your M.D. will ask that you (or your representative) sign an authorization before we use or disclose such information.  If you (or your representative) authorize Your M.D. to use or disclose your health information, you (or your representative) may revoke that authorization in writing at any time, except to the extent that it has already been acted upon. 

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

YOU HAVE THE FOLLOWING RIGHTS REGARDING YOUR HEALTH INFORMATION THAT YOUR M.D. MAINTAINS:

Receive Confidential Communications.  You (or your representative) have the right to request that Your M.D. communicate with you about your health and related issues in a particular manner or at a certain location.  For instance, you may ask that Your M.D. only communicate with you about your health privately with no other family members present.  All requests for confidential communications must be made in writing to Dr. Lewis at the address listed below.  Such requests shall specify the requested method of contact or the location where you wish to be contacted.  Your M.D. will accommodate reasonable requests.  You (or your representative) do not need to give a reason for your request.

Right to Request Restrictions.  You (or your representative) have the right to request restrictions on certain uses and disclosures of your health information.  For example, you (or your representative) may request a limit on Your M.D.’s disclosure of your health information to someone who is involved in your care or the payment of your care.  All requests for restrictions must be made in writing to Dr. Lewis at the address listed below.  Your M.D. is not required to agree to your request; however, if we do agree, we are bound by that agreement except when otherwise required by law or in emergencies.  Except as otherwise required by law, Your M.D. must agree to a restriction if:  (1) the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment); and (2) the health information pertains solely to a health care item or service for which Your M.D. has been paid out of pocket, in full, by you or someone else on your behalf (not the health plan).  If you selfpay and request a restriction, it will apply only to those health records created on the date that you received the item or service for which you, or another person (other than the health plan) on your behalf, paid in full, and which document the item or service provided on such date.

Right to Inspect and Copy Your Health Information.  You (or your representative) have the right to inspect and copy your health information, including billing records.  All requests to inspect and copy records must be made in writing to Dr. Lewis at the address listed below.  If you (or your representative) request a copy of your health information, Your M.D. will provide you (or your representative) a copy of your records in the format you request, unless we cannot practicably do so.  Your M.D. may charge a reasonable fee for any copying and assembling costs associated with your request.  Your M.D. may deny your request to inspect and/or copy your health information in certain limited circumstances.  If Your M.D. denies your request, you (or your representative) may request that we provide you with a review of our denial.  Reviews will be conducted by a licensed health care professional who we have designated as a reviewing official, and who did not participate in the original decision to deny the request.

Right to Amend Your Health Information.  If you (or your representative) believe your health information is incorrect or incomplete, you (or your representative) have the right to request that Your M.D. amend your records.  That request may be made as long as Your M.D. still maintains your records, and must include a reason for the amendment.  All requests for amendment must be made in writing to Dr. Lewis at the address listed below.  Your M.D. may deny the request if it is not in writing or does not include a reason for the amendment.  The request may also be denied if the requested amendment pertains to your health information that was not created by Your M.D., if the records you are requesting to amend are not part of Your M.D.’s records, if the health information you wish to amend is not part of the health information you (or your representative) are permitted to inspect and copy, or if, in the opinion of Your M.D., the records containing your health information are accurate and complete.

Right to an Accounting.  You (or your representative) have the right to request an accounting of disclosures of your health information made by Your M.D. for certain purposes.  All requests for an accounting must be made in writing to Dr. Lewis at the address listed below.  The request should specify the time period for the accounting, which may not exceed six years.  Your M.D. will provide the first accounting you request during any 12-month period without charge.  Subsequent accounting requests may be subject to a reasonable cost-based fee.

Right to a Paper Copy of this Notice.  You (or your representative) have the right to receive a separate paper copy of this Notice at any time even if you (or your representative) have received this Notice previously.  To obtain a separate paper copy, please contact Dr. Lewis at the phone number listed below.  A copy of our most current Notice may also be found on our website, www.yourmdmequon.com.

Right to Breach Notification.  You (or your representative) have the right to be notified of any breach of your unsecured health information.  Notification of a breach may be delayed or not provided if so required by a law enforcement official.  If you are deceased and there is a breach of your health information, the notice will be provided to your next of kin or personal representative if Your M.D. knows the identity and address of such individual.

CONTACT PERSON

Your M.D. has designated the Privacy Officer as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards.  If you have any questions or concerns regarding this Notice or your privacy rights, please contact the Privacy Officer, Dr. Richard A. Lewis, at (262) 226-8899.  You may also write to Dr. Lewis at the following address:

Your M.D.

Attention:  Dr. Richard A. Lewis

11649 North Port Washington Road, Suite 114

Mequon, Wisconsin 53092

COMPLAINTS

Your M.D. encourages you to express any concerns you may have regarding the privacy of your health information.  You will not be retaliated against in any way for expressing your concerns or filing a complaint.  You (or your representative) have the right to express complaints to Your M.D. or to the Secretary of Health and Human Services if you (or your representative) believe that your privacy rights have been violated.  Any complaints to Your M.D. may be made by calling Dr. Lewis at (262) 226-8899 or by writing to 11649 North Port Washington Road, Suite 114, Mequon, Wisconsin 53092.    

EFFECTIVE DATE:

This Notice is effective July 14, 2015.