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.
Dr. Stephen Emiley may use your health information as defined in the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment and evaluation, obtaining payment for your care, and conducting health care operations. Dr. Emiley has established a policy to guard against unnecessary disclosure of your health data.
THE FOLLOWING IS A SUMMARY OF CIRCUMSTANCES AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
TO PROVIDE TREATMENT: Provider may use your health information to provide care to you and disclose health information to others who provide care to you. For example, physicians involved with your care may need information about your symptoms in order to provide appropriate medications.
TO OBTAIN PAYMENT: Provider may include your health information in invoices to collect payment from third parties for the care you receive from Provider. For example, Provider may be required by your health insurance to provide information regarding your health care status so that the insurer will reimburse you or Provider.
TO CONDUCT HEALTH CARE OPERATIONS: Provider may use and disclose health information for its operations in order to facilitate the functions of Provider and as necessary to provide quality care to all of Provider's clients. Health care operations include activities such as: quality assessment and improvement activities, certification or licensing activities, review and auditing, including compliance reviews, business management and general administrative activities, case management and coordination, and research and protocol development.
FOR TREATMENT ALTERNATIVES: Provider may use your health information to inform you of possible treatment options or alternatives that may be of interest to you.
WHEN LEGALLY REQUIRED: Provider will disclose your health information when it is required to do so by Federal, State, or local law.
TO REPORT ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: Provider is allowed to notify authorities if Provider believes patient is the victim of abuse, neglect, or domestic violence when specifically required or authorized by law or when the client agrees to the disclosure.
TO CONDUCT HEALTH OVERSIGHT ACTIVIES: Provider may disclose your health information to health oversight agency for activities including: audits; civil, administrative, or criminal investigations; licensure or disciplinary action.
IN CONNECTION WITH JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: As permitted or required by law, Provider may disclose your health care information in the course of judicial or administrative proceedings in response to an order of a court or administrative tribunal or in response to a subpoena, discovery request, or other lawful process, but Provider will make reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
IN THE EVENT OF A SERIOUS THREAT TO HEALTH AND SAFETY: Provider may, consistent with applicable law and ethical standards of conduct, disclose your health information if Provider, 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 that of the public.
AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION
Other than stated above, Provider will not disclose your health information other than with your written authorization. You or your representative may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
RIGHT TO REQUEST RESTRICTIONS: You may request restrictions on certain uses and disclosures of your health information to someone who is involved in your care or the payment of your care. However, the Provider is not required to agree to your request. If you make a request for restrictions, contact Dr. Emiley.
RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS: You have the right to request Provider to communicate with you in a certain way. For example, you may request private sharing of information without other family members present. If you wish to receive confidential communications, contact Dr. Emiley.
RIGHT TO INSPECT AND COPY YOUR HEALTH INFORMATION: You have the right to inspect and copy your health information, including billing records. Such a request should be made to Dr. Emiley. Provider may charge a reasonable fee for copying and assembling costs associated with this request.
RIGHT TO AMEND YOUR HEALTH INFORMATION: You or your representative have the right to request Provider amend your records, if you believe your health information records are inaccurate or incomplete. Such a request and the reason for the amendment must be made in writing to Dr. Emiley. The request may be denied if your health records were not created by Provider, if the records are not part of Provider's records, if the health information is not material you are permitted to inspect and copy, or, if in the opinion of the Provider, the records containing your health information are accurate and complete.
RIGHTS TO AN ACCOUNTING: You or your representative have the right to request an accounting of disclosures of your health information made by Provider. The request must be made in writing to Dr. Emiley. The request should specify the time starting April 14, 2003 and requests may not be made for periods of time in excess of six (6) years. Provider will provide the first accounting during any 12 month period without charge. Subsequent 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 a separate paper copy of this Notice by contacting Dr. Emiley.
DUTIES OF PROVIDER
Provider is required by law to maintain the privacy of your health information and give you this Notice of its duties and privacy practices. Provider is required to abide by the terms of this Notice as may be amended from time to time. Provider reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If Provider makes a material change to this Notice, Provider will provide a copy of the revised Notice to you or your representative. You or your representative have the right to express complaints to Provider and the Secretary of Health and Human Services if you or your representative believe your privacy rights have been violated. Any complaints to Provider should be made in writing to Dr. Emiley. Provider encourages you to express any concerns you may have regarding the privacy of your information and will not retaliate against you in any way for filing a complaint.
Dr. Emiley is the designated contact person for all issues regarding patient privacy under the Federal privacy standards. He can be contacted at 414-961-0030 or in writing at 5900 N. Port Washington Road - Suite A-130, Glendale, WI 53217.
The effective date of this Notice is April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, CONTACT DR. EMILEY (414-961-0030).