Privacy Practices

Notice of Provider Privacy Practices1

Association of Hospital Anesthesiologists, SC is required by law to maintain the privacy of your health information. Association of Hospital Anesthesiologists, SC is also required to provide you with a notice that describes Association of Hospital Anesthesiologists, SC legal duties and privacy practices and your privacy rights with respect to your health information. We will follow the privacy practices described in this notice. If you have any questions about any part of this Notice or if you want more information about the privacy practices of Association of Hospital Anesthesiologists, SC, please contact Marcia Carlson at 844-693-1483.

We reserve the right to change the privacy practices described in this notice in the event that the practices need to be changed to be in compliance with the law. We will make the new notice provisions effective for all the protected health information that we maintain. If we change our privacy practices, we will have them available upon request. It will also be posted at the location of service.

How Association of Hospital Anesthesiologists, SC May Use or Disclose Your Health Information for Treatment, Payment or Health Care Operations

The following categories describe the ways that Association of Hospital Anesthesiologists, SC may use and disclose your health information.  For each type of use and disclosure, we will explain what we mean and present some examples.  

Treatment.  We may use or disclose your health care information in the provision, coordination or management of your health care. Our communications to you may be by telephone, cell phone, e-mail, patient portal, or by mail.  For example we may use your information to call and remind you of an appointment or to refer your care to another physician. If another provider requests your health information and they are not providing care and treatment to you we will request an authorization from you before providing your information.

Payment.  We may use or disclose your health care information to obtain payment for your health care services. For example, we may use your information if we send a bill for your health care services to your insurer.

Health Care Operations.  We may use or disclose your health care information for activities relating to the evaluation of patient care, evaluating the performance of health care providers, business planning and compliance with the law. For example, we may use your information to determine the quality of care you received when you had your surgery. If the activities require disclosure outside of our health care organization we will request your authorization before disclosing that information.

How Association of Hospital Anesthesiologists, SC May Use or Disclose Your Health Information Without Your Written Authorization[1]

The following categories describe the ways that Association of Hospital Anesthesiologists, SC may use and disclose your health information without your authorization.  For each type of use and disclosure, we will explain what we mean and present some examples.

  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 report child abuse or to respond to a court order.
  2. Public Health. We may release your health information to local, state or federal public health agencies subject to the provisions of applicable state and federal law 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 violence relating to children or the elderly.
  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 of the health care system.
  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. Under most circumstances when the request is made through a subpoena, a discovery request or involves another type of administrative order, your authorization will be obtained before disclosure is permitted.
  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 purposes. Under some limited circumstances we will request your authorization prior to permitting disclosure.
  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. Cadaveric, Organ, Eye or Tissue Donation. If we are a hospital, we may disclose your health information to organizations involved in procuring organs and tissues for transplantation.
  9. Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct medical research which may involve an assessment of how well a drug is working to cure a heart disease or whether a certain treatment is working better than another.
  10. 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. Disclosure is usually limited to law enforcement personnel who are involved in protecting the public safety.
  11. 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.
  12. 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. These programs may provide benefits for work-related injuries or illness.
  13. Health Information. We may use or disclose your health information to provide information to you about treatment alternatives or other health related benefits and services that may be of interest to you.
  14. Association of Hospital Anesthesiologists, SC   Unless you object, we may use your health information, such as your name, location in our facility, your general health condition (e.g., “stable,” or “unstable”), and your religious affiliation for our 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.  The information about you contained in our directory will not be disclosed to individuals not associated with our health care environment without your authorization. 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:
    1. 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;
    2. 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
    3. To disaster relief agencies—we may release your health information to an agency authorized by law to assist in disaster relief activities.

When Association of Hospital Anesthesiologists, SC is Required to Obtain an Authorization to Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you.  For example, uses and disclosures made for the purpose of psychotherapy, marketing and the sale of protected health information require your authorization.   If your provider intends to engage in fundraising, you have the right to opt out of receiving such communications.  If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.  If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.

Your Health Information Rights

  1. Inspect And Copy Your Health Information. You have the right to inspect and obtain a copy of your health care information. You have the right to request that the copy be provided in an electronic form or format  If the form and format are not readily producible, then the organization will work with you to provide it in a reasonable electronic form or format. For example, you may request a copy of your immunization record from your health care provider. This right of access does not apply to psychotherapy notes, which are maintained for the personal use of a mental health professional. Your request for inspection or access must be submitted in writing to 2109B E. Capitol Drive, Suite 1, Appleton, WI 54911 (844-693-1483). In addition, we may charge you a reasonable fee to cover our expenses for copying your health information.
  2. Request To Correct Your Health Information. You have a right to request that Association of Hospital Anesthesiologists, SC amend your health information that you believe is incorrect or incomplete. For example, if you believe the date of your surgery is incorrect; you may request that the information be corrected. We are not required to change your health information and if your request is denied, we will provide you with information about our denial and how you can disagree with the denial.  To request an amendment, you must make you request in writing to 2109B E. Capitol Drive, Suite 1, Appleton, WI 54911. You must also provide a reason for your request.
  3. Request Restrictions on Certain Uses and Disclosures. You have the right to request restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities.  For example, if you are an employee in a clinic and you receive health care services in that clinic, you may request that your medical record not be stored with the other clinic records. However, we are not required to agree in all circumstances to your requested restrictions, except in the case of a disclosure restricted to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service for which you, or the person other than the health plan on your behalf, has paid the covered entity in full.  If you would like to make a request for restrictions, you must submit your request in writing to 2109B E. Capitol Drive, Suite 1, Appleton, WI 54911.
  4. Receive Confidential Communications Of Health Information. You have the right to request that we communicate your health information to you in different ways or places.  For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address.  We must accommodate reasonable requests.
    To request confidential communications, you must submit your request in writing to 2109B E. Capitol Drive, Suite 1, Appleton, WI 54911.
  5. Receive A Record Of Disclosures Of Your Health Information. You have the right to request a list of the disclosures of your health information that we have made in compliance with federal and state law. This list will 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.  For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made.
    For example, you may request a list that indicates all the disclosures your health care provider has made from you health care record in the past six months. To request this accounting of disclosures, you must submit your request in writing to 2109B E. Capitol Drive, Suite 1, Appleton, WI 54911. We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.
  6.  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 agreed to receive this notice electronically. To obtain a paper copy of this Notice, send your written request to 2109B E. Capitol Drive, Suite 1, Appleton, WI 54911.
  7. Notified of a Breach. Your provider is required by law to maintain the privacy of protected health information and provide you with notice of its legal duties and privacy practices with respect to protected health information and to notify you following a breach of unsecured protected health information.
  8. Complaint. If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer that will provide you with any needed assistance. We request that you file your complaint in writing so that we may better assist in the investigation of your complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.  If your complaint relates to your privacy rights while you were receiving treatment for mental illness, alcohol or drug abuse or a developmental disability you may also file a complaint with the staff or administrator of the treatment facility or community mental health program.[2] There will be no retaliation against you in any way for filing a complaint.[3]

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact our Privacy Officer at 844-693-1483.

Optional Notice Sections

In addition to the above requirements, providers may also wish to include the following items in the privacy notice:

  1. Information about a joint notice.  Providers that participate in Organized Health Care Arrangements (OHCAs) may comply with HIPAA by issuing a joint notice, provided that:
    1. The covered entities participating in the OHCA agree to abide by the terms of the notice with respect to protected health information created or received by the covered entity as part of its participation in the OHCA.
    2. The joint notice incorporates all the requirements listed above, except that the statements required above may be altered to reflect the fact that the notice covers more than one covered entity.
    3. The notice describes with reasonable specificity the covered entities, or class of entities, to which the joint notice applies.
    4. The notice describes with reasonable specificity the service deliver sites, or classes of delivery sites, to which the joint notices applied; and
    5. If applicable, the notice should state that the covered entities participating in the OHCA will share protected health information with each other, as necessary to carry out treatment, payment, or health care operations relating to the OHCA.

    In addition, a joint notice may state that provision of the joint notice to an individual by any one of the OHCA participants will satisfy HIPAA provision requirements with respect to all others covered by the joint notice.

  2. If the provider participates in a health information exchange, the notice needs to explain the sharing of the information.
    Example text:  We participate in a regional arrangement of health care organizations, who 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 to a hospital on an emergency basis and cannot provide important information about your health condition, this regional arrangement will allow us to make your health information from other participants available to those who need it to treat you at the hospital.  When it is needed, ready access to your health information means better care for you.  We store health information about our patients in a joint electronic medical record with other health care providers who participate in this regional arrangement.
  3. Under the FDA regulations regarding medical device tracking requirements, a patient receiving such device has the right to refuse to release, or refuse permission to release, the patient’s name, address, telephone number, and Social Security Number, or other identifying information for the purpose of tracking.  As a result, a provider may wish to incorporate this right of refusal in the privacy notice.
  4. If provider maintains a website that provides information about the provider’s customer service or benefits, the provider must prominently post its notice on the web site and make it available electronically through its website.  Consequently, a provider may wish to incorporate this language into its privacy notice.
  5. Providers may wish to include a statement about HIPAA’s minimum necessary rule, which states that when a provider uses or discloses health information, providers must make reasonable efforts to limit the health information to the minimum necessary to accomplish the intended purpose of the use or disclosure.  The minimum necessary standard does not apply to disclosures to: (a) health care providers for treatment; (b) disclosures made to the patient; (c) disclosures made pursuant to an authorization; (d) disclosures made to DHHS; (e) disclosures required by law; and (f) disclosures required for compliance with HIPAA
  6. If a provider decides to limit uses and disclosure permitted under HIPAA, the provider may describe these more limited uses and disclosures.
Privacy Form

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

The privacy of your protected health information is important to us. We have provided you with a copy of our Notice of Privacy Practices. It describes how your health information will be handled in various situations. We ask that you sign this form to acknowledge you received a copy of our Notice of Privacy Practices. This includes the situation where your first date of service occurred electronically.

I have received Ketamine Wellness Center's Privacy Notice.

I have read and understand the Privacy Practices

Signature Section

Effective Date of This Notice: January 1, 2017

Version History:
Prepared by:Reviewed by:Content Changed:
Julie Coleman, RHIA
Chris Duprey
Stacie Kemp, MSW, LCSW
Kathy Johnson
Chrisann Lemery, MS, RHIA, CHPS, FAHIMA
Jennifer Rust-Anderson, JD, CHC
Holly Schlenvogt, MSH, CPM
Julie Svoboda, RHIA
Judy Titera, MBA, CIPP/US, CIPP/IT		Privacy Networking GroupAdded breach notification, right to receive an electronic copy of information, genetic information use prohibited for underwriting purposes, and distribution of Notice when changes occur. **You may request a copy of the all the changes made in this current version by contacting administration at [email protected].
Original Version:

4/12/02 | Prepared by: Susan Manning, J.D.

Disclaimer

This Model Notice of Provider Privacy Practices is Copyright © by the HIPAA Collaborative of Wisconsin (“HIPAA COW”). It may be freely redistributed in its entirety provided that this copyright notice is not removed. When information from this document is used, HIPAA COW shall be referenced as a resource. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This Model Notice of Provider Privacy Practices is provided “as is” without any express or implied warranty. The Model Notice of Provider Privacy Practices is for educational purposes only and does not constitute legal advice. If you require legal advice, you should consult with an attorney. Unless otherwise noted, HIPAA COW has not addressed all state pre-emption issues related to this Model Notice of Provider Privacy Practices. Therefore, this document may need to be modified in order to comply with Wisconsin/state law.