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Notice of Medical Information Privacy
PDF Version
Plastic Surgery Associates/Bluemound Surgery Center is required by law to maintain the privacy of your personal health information and to provide you with this notice describing Plastic Surgery Associates/Bluemound Surgery Center legal duties and privacy practices concerning your health information, necessary to achieve the purpose of the use or disclosure. However, this minimum necessary rule does not apply if the disclosure is to a provider regarding your treatment, to you, or due to a legal requirement. Plastic Surgery Associates/Bluemound Surgery Center is required to abide by the privacy practices described in this notice.
However, Plastic Surgery Associates/Bluemound Surgery Center reserves the right to change the privacy practices described in this notice, in accordance with the law. Changes to Plastic Surgery Associates/Bluemound Surgery Center privacy practices would apply to all health information maintained by Plastic Surgery Associates/Bluemound Surgery Center. If Plastic Surgery Associates/Bluemound Surgery Center changes its privacy practices, Plastic Surgery Associates/Bluemound Surgery Center will furnish you with a revised copy of this privacy notice by mail.
With your written consent, Plastic Surgery Associates/Bluemound Surgery Center can use your health information for the following purposes:
1. Treatment. For example, a physician may use the information in your medical record to determine which treatment option, such as drug or surgery, best addresses your health needs. The treatment selected will be documented in your medical records, so that other health care professionals can make informed decisions about your care.
2. Payment. In order for an insurance company or other health insurer to pay for your treatment, Plastic Surgery Associates/Bluemound Surgery Center needs to submit a bill that identifies you, your diagnosis, and the treatment provided to you. As a result, with your written consent, Plastic Surgery Associates/Bluemound Surgery Center will pass such health information onto an insurer in order to help receive payment for your medical bills.
3. Health Care Operations. With your written consent Plastic Surgery Associates/Bluemound Surgery Center may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care delivered by Plastic Surgery Associates/Bluemound Surgery Center. These quality and cost improvement activities may include evaluating the performance of your physicians, nurses, and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to similar situated patients.
In addition, Plastic Surgery Associates/Bluemound Surgery Center may want to use your health information for appointment reminders. For example, Plastic Surgery Associates/Bluemound Surgery Center may view your medical record to determine the date and time of your next appointment with Plastic Surgery Associates/Bluemound Surgery Center, and then send you a reminder letter to help you remember the appointment, or Plastic Surgery Associates/Bluemound Surgery Center may review your medical information and determine that another treatment or a new service offered by Plastic Surgery Associates/Bluemound Surgery Center may interest you. For example, Plastic Surgery Associates /Bluemound Surgery Center may contact a cancer patient to notify the patient that Plastic Surgery Associates/Bluemound Surgery Center has a new cancer research facility, offering new treatment protocols.
Furthermore, Plastic Surgery Associates/Bluemound Surgery Center may want to use information found in your medical record, such as your name, address, phone number, and treatment dates, to contact you for fund-raising purposes. For example, in order to proved more charity care or otherwise improve the health of your community, Plastic Surgery Associates/Bluemound Surgery Center may want to raise additional money and therefore may contact you for a donation.
Without your written consent or authorization, Plastic Surgery Associates/Bluemound Surgery Center, can use your health information for the following purposes:
1. As required or permitted by law. In certain circumstances, Plastic Surgery Associates / Bluemound Surgery Center may have to report some of your health information to legal entities, such as law enforcement officials, court officials, or government agencies. Examples of such circumstances may be to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
2. For public health activities. Plastic Surgery Associates/Bluemound Surgery Center may be required to report your health information to authorities to help prevent or control disease, injury, or disability. This may include using your medical record to report certain diseases, injuries, birth or death information, information related to the jurisdiction of the Food and Drug Administration, or information related to child abuse or neglect. Plastic Surgery Associates/Bluemound Surgery Center may also have to report certain work-related illnesses and injuries to your employer so that workplace medical surveillance actives can be conducted.
3. For health oversight activities. Plastic Surgery Associates/Bluemound Surgery Center may disclose your health information to authorities for audit, investigation, inspection, licensure, disciplinary or other purposes related to oversight of the health care system or government benefit programs.
4. For activities related to death. Plastic Surgery Associates/Bluemound Surgery Center may disclose your health information to coroners, medical examiners, and funeral directors so they can carry out their duties related to your death, such as identifying the body, determining cause of death, or in the case of funeral directions, to carry out funeral preparation activities.
5. For organ, eye, or tissue donation. Plastic Surgery Associates/Bluemound Surgery Center may disclose your health information to entities involved in obtaining, banking, or transplanting organs, eyes, or tissue of cadavers for donation or transplantation purposes.
6. For research. Under certain circumstances, and only after a special approval process, Plastic Surgery Associates/Bluemound Surgery Center may use and disclose your health information to help conduct research. Such research might involve studies related to evaluating the effectiveness of a treatment.
7. To avoid a serious threat to your health or safety. As required by law and standards of ethical conduct, Plastic Surgery Associates/Bluemound Surgery Center may use or disclose your health information to the necessary authorities if Plastic Surgery Associates/Bluemound Surgery Center believes, in good faith, that such a use or disclosure is necessary to prevent or minimize a serious and imminent threat to your or the public’s health or safety.
8. For military, national security, or incarceration/law enforcement custody. If you are involved with the military, national security, or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, Plastic Surgery Associates/Bluemound Surgery Center may disclose your health information to the proper authorities so they may carry out their duties under the law.
9. For workers’ compensation. Plastic Surgery Associates/Bluemound Surgery Center may disclose your health information to the appropriate persons in order to comply with the laws related to workers’ compensation or other similar programs. These programs may provide benefits for work-related injuries or illnesses.
10. Plastic Surgery Associates/Bluemound Surgery Center Directory. Unless you object, Plastic Surgery Associates/Bluemound Surgery Center may use your health information, such as your name, location in Plastic Surgery Associates/Bluemound Surgery Center facility, your general health condition, (i.e. “stable” or “unstable”), and your religious affiliation for a Plastic Surgery Associates/Bluemound Surgery Center directory. The information about you contained in the Plastic Surgery Associates/Bluemound Surgery Center directory will be disclosed to people who ask for you by name. However, the information about your religious affiliation will only be disclosed to clergy. Plastic Surgery Associates/Bluemound Surgery Center may allow you to object or agree orally regarding the use of your health information for directory purposes.
11. To those involved with your care or payment of your care. If people such as family members, relatives, or close personal friends are helping care for you or helping you pay your medical bills, Plastic Surgery Associates/Bluemound Surgery Center may disclose relevant health information about you to these people. The information disclosed to these people may include your location within Plastic Surgery Associates/Bluemound Surgery Center facility, your general condition, or death. You have the right to object to such disclosure, unless you are incapacitated or there is an emergency. In addition, Plastic Surgery Associates/Bluemound Surgery Center may disclose your health information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location or health status. Plastic Surgery Associates/Bluemound Surgery Center may allow you to object or agree orally to such disclosure, unless there is an emergency.
Note: except for the situations listed above, any other use or disclosure of your health information requires, Plastic Surgery Associates/Bluemound Surgery Center to obtain your written authorization. You may withdraw your authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization please submit your written withdraw to:
Plastic Surgery Associates / Bluemound Surgery Center
N4 W22370 Bluemound Road
Waukesha, WI 53186
Attention: Judy F.
Your Health Information Rights
You have several rights with regard to you health information. If you wish to exercise any of the following rights, please contact Judy F.
Specifically you have the rights to:
1. Requesting restrictions on certain uses and disclosures. You have the right to notify Plastic Surgery Associates/Bluemound Surgery Center that you want restrictions placed on how your health information is used or to whom your information is disclosed, even if the restrictions affects your treatment or Plastic Surgery Associates/Bluemound Surgery Center payment or health care operation activities. Or, you may want to restrict the health information provided to family or friends involved in your care or payment of medical bills, you may also want to restrict the health information provided to authorities involved with disaster relief efforts. However, it should be noted that Plastic Surgery Associates/Bluemound Surgery Center is not required to agree in all circumstances to your requested restriction.
If you receive certain medical devices (for example, life-supporting devices used outside Plastic Surgery Associates/Bluemound Surgery Center’ facility) you may refuse to release your name, address, telephone number, social security number, other identifying information for purpose of tracking the medical device.
2. As applicable, receive confidential communication of health information. You have the right to request alternative means or location when Plastic Surgery Associates/Bluemound Surgery Center communicates your health information to you. Plastic Surgery Associates/Bluemound Surgery Center must accommodate reasonable requests.
3. To inspect and copy your health information. With a few exceptions, you have the right to inspect and obtained a copy of your health information. However, this right does not apply to psychotherapy notes or information compiled for judicial proceedings, for example. In addition, Plastic Surgery Associates/Bluemound Surgery Center may charge you a reasonable fee if you want a copy of your health information.
4. To amend your health information. If you believe your health information is incorrect, you may ask Plastic Surgery Associates/Bluemound Surgery Center to amend the information. You may be asked to make such requests in writing and give a reason as to why your health information should be changed. However, if Plastic Surgery Associates/Bluemound Surgery Center did not create the health information that you believe is incorrect, or if Plastic Surgery Associates/Bluemound Surgery Center disagrees with you and does not believe your health information is correct, Plastic Surgery Associates/Bluemound Surgery Center may deny your request.
5. To receive an accounting of disclosures of your health information. In some limited instances, you have the right to request an accounting of the disclosures of your health information Plastic Surgery Associates/Bluemound Surgery Center has made during the previous six years, but the request cannot include dates before April 14, 2003. This accounting must include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. Plastic Surgery Associates/Bluemound Surgery Center must comply with your request for an accounting within 60 days, unless you agree to a 30 day extension, and Plastic Surgery Associates/Bluemound Surgery Center may not charge you for the accounting, unless you request such accounting more than once per year. In addition, Plastic Surgery Associates/Bluemound Surgery Center will not include in the accounting disclosures made to you or for purposes of treatment, payment, health care operations, the Plastic Surgery Associates/Bluemound Surgery Center directory, national security, law enforcement/corrections, and certain health oversight activities.
6. To obtain a paper copy of this notice. Upon your request you may at any time receive a paper copy of this notice, even if you earlier agree to receive this notice electronically.
7. To complain. If you believe your privacy rights have been violated, you may file a complaint with Plastic Surgery Associates/Bluemound Surgery Center and with the Federal Department of Health and Human Services. Plastic Surgery Associates/Bluemound Surgery Center will not retaliate against you for filing such a complaint. To file a complaint with either entity please contact, Judy F. at Plastic Surgery Associates/Bluemound Surgery Center, who will provide you with the necessary assistance and paperwork.
Again, if you have any questions or concerns regarding your privacy rights or the information in this notice please contact Judy F. at Plastic Surgery Associates/Bluemound Surgery Center, (262) 970-5600.
This Notice of Medical Information Privacy is Effective April 14, 2003.
Your privacy is important to us.
This notices describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
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