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 CAREFULLY.

The effective date of this notice is September 25, 2015

Our Privacy Responsibilities
The law requires us to maintain the privacy and security of certain health information called “Protected Health Information” (“PHI”). PHI is the information that you provide us and that we create or receive about your health care, including medical records and billing information. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your PHI, we are required to follow the terms of this Notice (or the Notice in effect at the time we use or share your PHI). We will promptly notify you if a breach occurs that may have compromised the privacy or security of your PHI. Finally, the law provides you with certain rights, which are described further in this Notice.

When We May Use and Disclose Your Health Information With Your Written Authorization

Use or Disclosure With Your Authorization
For any purpose other than the ones described below, we may use or disclose your health information only when you give us your written authorization to do so. For example, we cannot send your health information to your life insurance company or sell your health information without your authorization.

Marketing
We must also obtain your written authorization before using your health information to send you any marketing materials. We can provide you with marketing materials in a face-to-face encounter or a promotional gift of very small value, if we so choose. We may communicate with you about products or services relating to your treatment, to coordinate or manage your care, or provide you with information about different treatments, providers or care settings.

Uses and Disclosures of Your Highly Confidential Information
Federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the part of your health information that is: (1) maintained in psychotherapy notes; (2) about treatment of mental illness or developmental disability; (3) about the identity, diagnosis, prognosis, or treatment for alcohol or drug dependency; (4) about HIV test results; or (5) about child abuse or neglect. Except for certain treatment purposes described in below, we will generally obtain your written authorization for uses or disclosures of Highly Confidential Information for the purposes described below. The only exception to this is if we are allowed by law to disclose your Highly Confidential Information for certain purposes without your written authorization. For example, we are allowed to disclose information about treatment of mental illness or developmental disability for program monitoring and evaluation, or to a physician in a medical emergency.

Ways We Can Use and Share Your PHI without Your Written Permission
In many situations, we can use and share your PHI without your written permission (authorization) for activities that are common in clinics and hospitals. In certain other situations, which we will describe below, we must have your authorization to use and/or share your PHI. Although we may not need your authorization for the following uses and disclosures of your PHI, we generally have to meet many conditions in the law before we can share your information for these purposes.

Treatment, Payment, and Healthcare Operations

Treatment
We use and share your PHI to provide and manage your health care and related services – for example, to diagnose and treat your injury or illness. We will share information with those who treated you before we saw you (such as your primary care provider or a referring specialist), and with those who will treat you in the future. This helps to make sure that everyone caring for you has the information they need. We will also share information with other third parties, such as pharmacies, home health agencies, rehabilitation hospitals, and ambulance companies.

Payment
We use and share your PHI to receive payment for services that we provide to you. For example, if you have health insurance, we will share your PHI with your health plan or government agency (for example, Medicare or Medicaid) in order to collect payment or to confirm that the entity will pay for your health care.

Health Care Operations
We can use and share your PHI for our health care operations, which include management, planning, and activities that help to improve the quality and efficiency of the care that we deliver. For example, we can use PHI to review the quality and skill of our health care providers and to provide them training. In addition, we sometimes share PHI with third parties who help us run our organization, including those we hire to perform services on our behalf.

To Contact You about Appointments, Insurance, and Other Matters
We may contact you by mail, phone, text, or email for many reasons, including to: remind you about an appointment, give you test results, ask about insurance, billing, or payment, follow up on your care, ask you how well we cared for you. We may leave voice messages at the telephone number you give to us. If you choose to have us contact you by text, texting charges may apply.

Disclosures to Business Associates
In order for us to carry out treatment, payment or health care operations, we may disclose your health information to persons or organizations that perform a service for or on our behalf that requires the use or disclosure of individually identifiable health information. Such persons or organizations are our business associates. For example, we may disclose your health information to a collection agency to collect payment of medical bills.

Public Health and Safety Activities
We can share your PHI to help with public health and safety issues: to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability, to report suspected abuse, neglect, or domestic violence to the appropriate State agencies, to report information to the U.S. Food and Drug Administration (FDA) about products and activities it regulates, to prevent or reduce a serious and imminent threat to anyone’s health or safety, as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

Health Oversight Activities
To the extent authorized by law, we can share your PHI with a health oversight agency that oversees the health care system and ensures the rules of government health programs, such as Medicare or Medicaid, are being followed.

Legal and Administrative Proceedings
If certain conditions are met, we can share your PHI in response to a court or administrative order. In most cases, we won’t share your information in response to a subpoena, unless it is accompanied by a binding court order or your written permission.

Law Enforcement Purposes
We can share your PHI with the police or other law enforcement officials as required or permitted by law, or in compliance with a court order.

Organ and Tissue Donation
Wisconsin generally requires patient consent to disclose mental health treatment records for organ or tissue donation purposes. In instances when consent is not required, we may disclose your health information to organizations that facilitate organ, eye or tissue donation, banking or transplantation.

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Coroners, Medical Examiners and Funeral Directors
We may disclose your health information to a coroner, medical examiner or funeral director as required or allowed by law. Wisconsin law generally requires consent of a patient’s authorized family or legal representative to release protected health information to funeral directors, however, HIV test results and certain other protected health information may be disclosed to a funeral director when necessary to permit the funeral director to carry out his/ her duties. Wisconsin law generally requires consent of a patient’s authorized family or legal representative or a court order to release mental health treatment records to a coroner or medical examiner.

Research
Patient consent is required before we may disclose protected health information for research purposes to a researcher who is not affiliated with Alliance Medical Group. In some situations, Alliance Medical Group may disclose protected health information for research purposes to a researcher who agrees to protect the privacy of your information. Private pay patients may be able to opt out of the use or disclosure of your information for research purposes.

Inmates
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official for certain purposes. For example, we may disclose your health information to a correctional institution to provide you with health care.

Workers’ Compensation
We can share your PHI as permitted or required by state law relating to workers’ compensation claims or other similar programs.

As Required by Law
We will use and share your PHI if state or federal laws require it.

Written Permission to Use and Share Your Protected Health Information
For purposes other than the types described, we will only use or share your PHI when you give us your written permission. For example, you will need to give us your written permission before we send your PHI to your life insurance company or your attorney. You may request an authorization form by contacting our clinic at 715-690-1272, or visiting in person. You may change your mind about your authorization to disclose your PHI by sending a written “revocation statement” to the attention of the medical records department at our clinic. The revocation will not apply to the extent that we have already taken action based on your prior authorization.

Certain Health Information
Some categories of health information are protected by additional state or federal privacy laws and regulations. In most cases, we will not be able to share the following types of health information without your written authorization: HIV testing and test results (except to other health care providers treating you when sharing is necessary in order to protect your health), genetic testing and test results, and addiction treatment program records.

Psychotherapy Notes
Except in very limited circumstances as permitted by law, we will not use or share psychotherapy notes without your written permission. Psychotherapy notes are those created for the therapist’s own use and maintained separate from the medical record. They do not include medical records generated in the course of psychology or psychiatry visits, such as progress/visit notes. Psychotherapy notes are rarely, if ever, created or maintained at Alliance Medical Group.

Your Rights Regarding Your Protected Health Information
All requests to exercise your rights described in this section must be in writing. If you wish to obtain request forms, or want additional information about how to exercise any of your rights described in this section, please contact the medical records department.

Right to Request Restrictions
You have the right to ask us to restrict or limit the PHI we use or share about you for treatment, payment, or health care operations purposes. However, we are not required to agree to your request (other than a request to restrict a disclosure to a health plan under the circumstances described below*) and we will not agree to a request if we feel it would affect your care or if we feel that we cannot carry out our agreement to do so.

*If you pay for a service or health care item out-of-pocket in full, we must agree to your request to restrict sharing that information (for the purpose of payment or our health care operations) to your health plan, unless we are required by law to share the information.

Right to Request Confidential Communications
You can ask us to communicate with you in specific ways (such as by letter or by phone), or at a certain location (for example, only at home). We will agree to your request if we feel it is reasonable.

Right to Receive an Electronic or Paper Copy of Your Medical Records
You can ask to see or get an electronic or paper copy of your medical records, billing records, and other records used to make decisions about you. Under limited circumstances, we may deny you access to a portion of your records if your provider feels that providing access could cause harm to you or someone else. We will usually provide a copy or summary of your health information within 30 days of your request. We may charge a reasonable, cost-based fee for copies of your record.

Right to Request We Correct (Amend) Your Records
You have the right to request that we correct /amend the information in your medical records, billing records, and other records used to make decisions about you that you think is incorrect or incomplete. If you want to request a correction or an amendment to your records, you may obtain a request form from the records clerk at Alliance Medical Group. Once we receive the completed form, we will comply with your request unless your provider believes that the information is correct and complete or other circumstances apply. We will notify you in writing of our decision within 60 days.

Right to Receive an Accounting of Disclosures
You have the right to request a list (accounting) of the times we have shared your PHI in the six years prior to the date of your request. The following types of disclosures are exempt from this accounting: disclosures made to carry out treatment, payment, or health care operations; disclosures made to you; incidental disclosures; disclosures made with your written permission; disclosures to those involved in your care, or for other notification purposes; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement officials regarding inmates in their custody; and those that were made as part of a limited data set.

Right to Notification of Breach
You have the right to be informed of a breach of your protected health information. We will notify you, within 60 days of discovery, if we breach your unsecured protected health information.

File a Complaint
If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact the Privacy Officer Alliance Medical Group. To file a complaint, please contact our Privacy Officer, Alliance Medical Group, 2417 Post Rd, Stevens Point, WI 54481. All complaints must be submitted in writing. You may also file a written complaint with the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services. When you ask, the Privacy Office will provide you with the current address for the OCR. You may also visit the OCR’s website for further information on filing a complaint: http://www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.

Change in Terms of this Notice
We may change the terms of this Notice at any time. If we change this Notice, we may make the new Notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new Notice. If we change this Notice, we will post the new Notice in common areas throughout our facilities, and on our Internet site at www.alliancehealthclinic.com. You also may obtain a copy of this Notice, including a paper copy, by contacting the staff at Alliance Medical Group.

If you have any questions about your privacy rights or the information contained in this notice, contact our clinic at 715-690-1272.

This notice effective September, 2015