Patient Services

Privacy Policy

The privacy of your medical information is important to us. This Prevea Health privacy practices 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.

To protect your privacy, print a copy of the HIPAA consent form for each member of your family, sign and mail it to the address below to update your medical records

HIPAA Consent Form

Summary of Privacy Practices

We may use and disclose your medical information, without your permission, for treatment, payment, and certain health care operations activities and, when required or authorized by law, for public health and interest activities, law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions. We may not disclose HIV test results or mental health treatment records for certain of these purposes without your written permission.

We may disclose your name and location in our facility to your family members, friends, and others you involve in your health care or payment for health care, and to appropriate public and private agencies in disaster relief situations.

We will not otherwise use or disclose your medical information without your written authorization.

You have the right to examine and receive a copy of your medical information, to receive an accounting of certain disclosures we may make of your medical information, and to request that we amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information.

Please review this entire notice for details about the uses and disclosures we may make of your medical information, about your rights and how to exercise them, and about complaints regarding or additional information about our privacy practices.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your medical information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect unless we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time; provided applicable law permits such changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice, post the revised notice at each of our service delivery sites, and make the new notice available to our patients and others upon request.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information at the end of this notice.

Uses and Disclosures of Medical Information Treatment

We may use your medical information, without your permission, to treat you. We may disclose your medical information, without your permission, to a physician or other health care provider for your treatment. These treatment activities include coordination of your care with other providers, with health plans and with others, consultation with other providers, and referral to other providers related to your care.

Payment

We may use and disclose your medical information, without your permission, to obtain or provide reimbursement for health care we provide to you, including submitting claims to health plans, other insurers or others. These payment activities include justifying our charges for and demonstrating the medical necessity of the care we deliver to you, determining your eligibility for health plan benefits for the care we furnish to you, obtaining pre-certification or preauthorization for your treatment or referral to other health care providers, participating in utilization review of the services we provide to you, and the like.

We may disclose your medical information to another health care provider or to a health plan for that provider or plan to obtain payment or engage in other payment activities with respect to your health care. We may need your written permission to disclose information taken from your mental health treatment records or HIV test results for payment purposes.

Health Care Operations

We may use and disclose your medical information for certain of our health care operations. Health care operations include:

• health care quality assessment and improvement activities;
• reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing and credentialing activities;
• conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention; and
• business planning, development, management, and general administration, including customer service, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

With your written permission, we may disclose your medical information to a health plan or another health care provider who is subject to federal privacy protection laws, as long as the provider or plan has or had a relationship with you and the medical information is for that provider's or plan's health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

We may need your written permission to disclose medical information or information taken from your mental health treatment records or HIV test results for certain health care operations.

Your Authorization

You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice.

Family, Friends, and Others Involved in Your Care or Payment for Care

We may disclose your name and location in our facilities without your written permission to a family member, friend or any other person you involve in your health care or payment for your health care. Before we disclose your name and location without your written permission, we will provide you with an opportunity to object.

If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing your name and location is in your best interest under the circumstances. We may use or disclose your name and location to notify, or to assist an appropriate public or private agency to locate and notify a person responsible for your health care in appropriate situations, such as a medical emergency or during disaster relief efforts.

With your written permission, we may disclose your confidential medical information to a family member, friend or any other person you involve in your health care or payment for your health care. We will disclose only the medical information that is relevant to the person's involvement.

Facility Directories

Unless you object when we ask you, we may list your name, your religious affiliation, and your location in our facility in our facility directories. We will disclose your religious affiliation only to clergy. We will disclose the other information only to persons who ask for you by name.

If you are not present or are incapacitated or it is an emergency, we will use our professional judgment and any prior preference you may have expressed, to determine if listing your information in our facility directories is in your best interest. If we list your information, we will ask whether you object to continuing the listing as soon as you become available. We may not disclose your general medical condition or any information taken from mental health treatment records or HIV test results in our facility directories without your written permission.

Health-Related Products and Services

We may use your medical information to contact you to provide appointment reminders, and to communicate with you about treatment alternatives and other health-related benefits and services that may be of interest to you. These communications may describe health-related products or services that we provide, payment for such products or services, and the health care providers in a provider or health plan network.

Public Health and Benefit Activities

We may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and interest activities, judicial and administrative proceedings, law enforcement, research, and other public benefit functions:

• for public health, including to report disease and vital statistics, child abuse, and adult abuse or neglect;
• to avert a serious and imminent threat to health or safety;
• for health care oversight, such as activities of state licensing and peer review authorities, and fraud prevention enforcement agencies;
• for research;
• in response to court and certain administrative orders and other lawful process;
• to law enforcement officials with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons;
• to coroners, medical examiners, and (with respect to HIV test results) funeral directors;
• to organ procurement organizations by a hospital;
• to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
• as authorized by state worker's compensation laws.

You may be able to opt out of use or disclosure of your medical information for (a) research purposes or (b) pursuant to a written request from a government agency, unless a law requires the disclosure.

We may not disclose HIV test results, certain confidential medical information or mental health treatment records for certain of these purposes without your written permission, unless required by law. Your HIV test results, if any, may be disclosed as set forth in Wisconsin Statutes § 252.15(5)(a). A listing of the persons or circumstances set forth in that statute is available on request.

Individual Rights

Access: You have the right to examine and to receive a copy of your medical information, with limited exceptions. You must make a written request to obtain access to your medical information. You should submit your request to the contact at the end of this notice. You may obtain a form from that contact to make your request. We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request.

Contact us using the information at the end of this notice for information about our fees.

Disclosure Accounting

You have the right to a list of instances after April 13, 2003 in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities. You also have the right to a list of all written disclosures of your mental health treatment records.

You should submit your request to the contact at the end of this notice. You may obtain a form from that contact to make your request. We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request and never for a disclosure that occurred before April 14, 2003. 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 your additional requests. Contact us using the information at the end of this notice for information about our fees.

Amendment

You have the right to request that we amend your medical information and mental health treatment records. Your request must be in writing and must explain why the information should be amended. You should submit your request to the contact at the end of this notice. You may obtain a form from that contact to make your request.

We may deny your request only for certain reasons. If we deny your request, we will provide you a written explanation. If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the un-amended information to your detriment, as well as persons you want to receive the amendment.

Restriction

You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify. We are not required to agree to your request. If we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law. You should submit your request to the contact at the end of this notice. You may obtain a form from that contact to make your request. Any agreement we may make to a request for restriction must be in writing signed by a person authorized to bind us to such an agreement.

Confidential Communication

You have the right to request that we communicate with you about your medical information in confidence by alternative means or to alternative locations that you specify. You must make your request in writing. You should submit your request to the contact at the end of this notice. You may obtain a form from that contact to make your request. We will accommodate your request if it is reasonable, specifies the alternative means or location for confidential communication, and explains how payment for our services will be handled under the alternative means or alternative location you request for confidential communication of your medical information. We will not ask you to explain the reason for your request.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us using the information at listed below. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, in response to a request you made to amend, restrict the use or disclosure of, or communicate in confidence about your medical information, you may complain to us using the contact information at the end of this notice. You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office of Civil Rights' Hotline at 1-800-368-1019. We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Office

Prevea Health Center

HIPAA Privacy Official - Compliance Department

760 Pilgrim Way Green Bay, WI 54307

Telephone: 920-496-4700 Fax: 920-405-1466

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