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.
Bluemound Surgery Center is required by law to maintain the privacy of your personal health information and to provide you with this notice describing 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. Bluemound Surgery Center is required to abide by the privacy practices described in this notice.
However, Bluemound Surgery Center reserves the right to change the privacy practices described in this notice, in accordance with the law. Changes to Bluemound Surgery Center privacy practices would apply to all health information maintained by Bluemound Surgery Center. If Bluemound Surgery Center changes its privacy practices, Bluemound Surgery Center will furnish you with a revised copy of this privacy notice by mail.
With your written consent, 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 a 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, 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, 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 Bluemound Surgery Center may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care delivered by 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, Bluemound Surgery Center may want to use your health information for appointment reminders. For example, Bluemound Surgery Center may view your medical record to determine the date and time of your next appointment with Bluemound Surgery Center, and then send you a reminder letter to help you remember the appointment, or Bluemound Surgery Center may review your medical information and determine that another treatment or a new service offered by Bluemound Surgery Center may interest you. For example, Bluemound Surgery Center may contact a cancer patient to notify the patient that Bluemound Surgery Center has a new cancer research facility, offering new treatment protocols.
Furthermore, 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 for fund-raising purposes. For example, in order to provide more charity care or otherwise improve the health of your community, Bluemound Surgery Center may want to raise additional money and therefore may contact you for a donation.
Without your written consent or authorization, Bluemound Surgery Center, can use your health information for the following purposes:
1. As required or permitted by law. In certain circumstances, 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. 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. Bluemound Surgery Center may also have to report certain work-related illnesses and injuries to your employer so that workplace medical surveillance activities can be conducted.
3. For health oversight activities. Bluemound Surgery Center may dsiclsoe 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. 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. 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, 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, Bluemound Surgery Center may use or disclose your health information to the necessary authorities if 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 inthe custody of law enforcement officials or an inmate in a correctional institution, 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. 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. Bluemound Surgery Center Directory. Unless you object, Bluemound Surgery Center may use your health information, such as your name, location in Bluemound Surgery Center facility, your general health condition (i.e. “stable” or “unstable”), and your religious affiliation for a Bluemound Surgery Center directory. The information about you contained in the 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. 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, Bluemound Surgery Center may disclose relevant health information about you to these people. The information disclosed to these people may include your location with Bluemound Surgery Center facility, your general condition, or death. You the the right to object to such disclosure, unless you are incapacitated or there is an emergency. In addition, 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. 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, 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:
Bluemound Surgery Center
N4 W22370 Bluemound Road
Waukesha, WI 53186
Attention: George Korkos, M.D.
Your Health Information Rights
You have several rights with regard to your health information. If you wish to exercise any of the following rights, please contact George Korkos, M.D. Specifically you have the rights to:
1. Requesting restrictions on certain uses and disclosures. You have the right to notify Bluemound Surgery Center that you want restrictions placed on how you health information is used or to whom your information is disclosed, even if the restrictions affect your treatment or 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 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 Bluemound Surgery Center’s 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 Bluemound Surgery Center communicates your health information to you. 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 obtain 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, 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 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 Bluemound Surgery Center did not create the health information that you believe is incorrect, or if Bluemound Surgery Center disagrees with you and does not believe your health information is correct, 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 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 disclosed, and why the disclosure was made. Bluemound Surgery Center must comply with your request for an accounting within 60 days, unless you agree with a 30 day extension, and Bluemound Surgery Center may not charge you for the accounting, unless you request such accounting more than once per year. In addition, Bluemound Surgery Center will not include in the accouthing discoosure made to you or for purposes of treatment, payment, health care operations, the 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 Bluemound Surgery Center and with the Federal Department of Health and Human Services. Bluemound Surgery Center will not retaliate against you for filing such a complaint. To file a complaint please contact, George Korkos, M.D. at 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 George Korkos, M.D. at Bluemound Surgery Center, (262) 970-5600.
This Notice of Medical Information Privacy is Effective April 14, 2003.