USES AND DISCLOSURES WE MAY MAKE WITHOUT
WRITTEN AUTHORIZATION: We may use or disclose your
health information for certain purposes without your written authorization, including the following:
Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.
Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims
management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.
Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.
OTHER USES AND DISCLOSURES. We may also use or disclose your information for certain other purposes allowed by
45 CFR 164.512 or other applicable laws and regulations,
including the following:
Disaster Relief. We may use or disclose your health
information to assist in disaster relief efforts.
Required by Law/Personal and Public safety. We may use or disclose your health information when we are required to do so by law and to avoid a serious threat to your health or safety or the health and/or safety of others.
USES AND DISCLOSURES WITH YOUR WRITTEN
AUTHORIZATION. Other uses and disclosures not described in this Notice will be made only with your written authorization, including most uses or disclosures of psychotherapy notes. You may revoke your authorization by submitting a written notice to the Privacy Contact identied below. The revocation will not be effective to the extent we have already taken action in reliance on the authorization.
Public Health Activities. We may disclose your health
information for public health activities, including disclosures to:
Coroners, Medical Examiners, and Funeral Directors. We
may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
DISCLOSURES WE MAY MAKE UNLESS YOU OBJECT.
Unless you instruct us otherwise, we may disclose your information as described below.
Individuals Involved in Your Care or Payment for Your Care.
We may disclose your health information to your family or friends or any other individual identied by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.
Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.
Appointment reminders. We may use or disclose your health information to provide you with appointment reminders such as voicemail, messages, postcards, or letters.
YOUR HEALTH INFORMATION RIGHTS
Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request In writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will use the form and format you request if readily producible. We reserve the right to charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
Disclosure Accounting. With the exception of certain
disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Ofcial. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional
requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree
to your request, but if we do, we will abide by our agreement except in an emergency. You have the right to restrict information given to your third-party payer or health plan if you fully pay for the services out of your pocket.
National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.
Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the
extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Law Enforcement. We may disclose your PHI for law
enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.
Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Research. We may disclose your PHI to researchers when
their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.
Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests.
Amendment. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law. The notification will occur by rst class mail within 60 days of discovery of a breach. A breach occurs when there has been unauthorized use or disclosure under HIPAA that compromises the privacy or security of PHI. There are three exceptions to the dentition of what a breach is. An impermissible use or disclosure of PHI is presumed to be a breach unless we can demonstrate that there is a low probability that the PHI has been compromised. The notification requirements under this section apply only if it does not fall into one of the three exceptions or if we cannot demonstrate that there is a low probability that the PHI has been compromised. If we are required to provide notice to you, the notice will contain the following information:
(1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach;
(2) the steps you should take to protect yourself from potential harm resulting from the breach; and
(3) a brief description of what we are doing to investigate the breach, mitigate losses, and protect against further reaches.
Not every impermissible use or disclosure of protected health information constitutes a reportable breach. The determination of whether an impermissible breach is reportable hinges on whether there is a low probability that the PHI has been compromised. In order to determine whether there is a low probability that your PHI has been compromised, we will conduct a risk assessment using the four-factor analysis outlined in the Omnibus Final Rule that became effective March 26, 2013.
Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (email).
Questions and Complaints
If would like more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health 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 le your complaint with
the U.S. Department of Health and Human Services upon
request.
Submit complaints, concerns or questions to our Privacy Officer.
422 2nd Street
Hudson, WI 54016
Telephone: 715-381-9710
Fax: 715-381-9728
Updated November 1, 2024
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