LakeView Medical Center - Notice of Privacy Practices
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Notice of Privacy Practices


Notice of Privacy Practices HIPAA FORM 9
LAKEVIEW MEDICAL CENTER
1700 West Stout Street
Rice Lake, WI 54868
NOTICE OF PRIVACY PRACTICES
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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

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 4/14/2003, and will remain in effect until further requirements or recommended changes are made.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. 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 and make the new notice available 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 listed at the end of this notice.

{Organizations Covered by this Notice}
 
{This notice applies to the privacy practices of the {types of} organizations listed below, with the {classes of} sites they maintain for delivery of health care products and services. These organizations are each participants in an organized health care arrangement. As such, we may share your medical information and the medical information of others we service with each other as needed for treatment, payment or health care operations relating to our organized health care arrangement.}
 
  • Lakeview Medical Center
  • Marshfield Clinic
  • Diagnostic Radiology Associates
  • Dr. Hager
  • Dr. Iwakari
  • Branham and Healy Orthopedic Clinic
  • Dr. Weber, Dr. Raether, Dr. Henkel, and Dr. Anderegg
  • Chippewa Valley Eye Clinic
  • Dr. Rieser & Dr. Thomas
  • Dr. Mack and Dr. Kowski (Foot and Ankle Clinic)

Uses and Disclosures of Medical Information
We may use and disclose medical information about you for treatment, payment, and health care operations. For example:

Treatment:
We may use or disclose your medical information to a physician or other health care provider providing treatment to you.

Payment:
We may use and disclose your medical information to obtain payment for services we provide to you.

Health Care Operations:
We may use and disclose your medical information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

To You and on Your Authorization:
We must disclose your medical information to you, as described in the Individual Rights section of this notice. 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 disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your medical information for any reason except those described in this notice.

Facility Directory:
We may use the following medical information in our facility directories: your name and location in our facility. We will disclose this information to members of the clergy and to other persons who ask for you by name. You may restrict or prohibit some or all disclosures for facility directories unless emergency circumstances prevent your opportunity to object. We may not disclose your general medical condition in our facility directories without your written permission.

Persons Involved In Your Care:
With your written permission, we may disclose to a family member, friend or other person, the medical information that is directly relevant to their involvement in your care or payment for your care. We may use or disclose your name and location (and, with your written permission, general condition or death) to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person involved in your care. If you have not previously given us written permission for such uses and disclosures and are present, we will provide you with an opportunity to object to such uses or disclosures.
We may also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of medical information.

Disaster Relief:
We may use or disclose your name and location to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

Marketing Health Related Services:
We may use your medical information to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you. With your written permission, we may disclose your medical information to a business associate to assist us in these activities. Unless the information is provided to you by a general newsletter or in person or is for products or services of nominal value, you may opt out of receiving further such information by telling us using the information listed at the end of this notice.

Fundraising:
We may use your medical information to contact you for fundraising purposes. We will limit our use and disclosure to your demographic information and the dates of your health care. With your written permission, we may disclose this information to a foundation affiliated with us or a business associate to assist us in fundraising activities. We will provide you with any fundraising materials and a description of how you may opt out of receiving future fundraising communications.

Death; Organ Donation:
We may disclose the medical information of a deceased person to a coroner, medical examiner, or organ procurement organization for certain purposes.

Required by Law:
We may use or disclose your medical information when we are required to do so by law. For example, we must disclose your medical information to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws. We may disclose your medical information when authorized by workers' compensation or similar laws. We may disclose your medical information to a government agency authorized to oversee the health care system or government programs or its contractors, to public health authorities for public health purposes, and to any government agency which makes a written request for a legally authorized purpose. You may be able to opt out of some of these disclosures to government agencies.

Law Enforcement:
We may disclose your medical information in response to a court order and certain administrative orders, subpoenas, discovery requests, or other lawful process. We may disclose limited information to a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person, or when necessary to assist law enforcement officials to capture and individual who has admitted to participation in a crime or has escaped from lawful custody.
We may disclose the medical information of an inmate or other person in lawful custody to a law enforcement official or correctional institution under certain circumstances.

Abuse, Neglect or Endangerment:
We may disclose your medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse or neglect. We may disclose your medical information to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others.

National Security:
We may disclose to military authorities the medical information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials medical information required for lawful intelligence, counterintelligence, and other national security activities. You may be able to opt out of some of these disclosures to government agencies.

HIV Test Results.
Your HIV test results, if any, may be disclosed as set forth in Wisconsin Statues 252.15(5)(a). A listing of the persons or circumstances set forth in that statute is available on request. Written authorization is required for release of HIV results outside of the WI statutes as listed above.
Individual Rights

Access:
You have the right to look at or get copies of your medical information, with limited exceptions. {You must make a request in writing to obtain access to your medical information. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, there will be a charge set forth by MedLegal, our release of information specialists, for staff time to locate and copy your medical information. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.}

Disclosure Accounting:
You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes, other than treatment, payment, health care operations for which we have written permission, and certain other activities, since April 14, 2003. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your medical information, a description of the medical information we disclosed, the reason for the disclosure, and certain other information.
If you request a disclosure accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.

Restriction:
You have the right to request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). {Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is so memorialized in writing.}

Confidential Communications:
You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. {You must make your request in writing, and you must state that the information could endanger you if it is not communicated by the alternative means or to the alternative location you want.} We must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment.
You have the right to request that we amend your medical information. {Your request must be in writing, and it must explain why the information should be amended.} We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Electronic Notice:
If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain this notice in written form.


Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.

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 or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may file a complaint by 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 file your complaint with the U.S. Department of Health and Human Services upon request.

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: Health Information Services
Telephone: 715-236-6135
Fax: 715-236-6573
E-Mail: piecuch.debra@lakeviewmedical.org
Address: 1700 West Stout Street, Rice Lake, WI 54868