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.
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.
“Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.
It is your right as a patient to be informed of Wascher Cervical Spine Institute’s legal duties with respect to the protection of the privacy of your personal health information.
Wascher Cervical Spine Institute is required to:
Wascher Cervical Spine Institute reserves the right to change the terms of the notice of privacy practice 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.
If you have any questions about any part of this Notice, or if you want more information about the privacy practices of Wascher Cervical Spine Institute, please contact the Privacy Officer at (855) 854-9274.
Request a Restriction on Certain Uses and Disclosures
You have the right to request restrictions on certain uses and disclosures of protected health information for treatment, payment, health care operations, communications to family or friends or disclosure to disaster relief agencies. We are not required to agree to or grant restriction requests. We will honor your request to restrict disclosure of your protected health information to your health plan for payment and healthcare operations purpose and if not otherwise required by law when you or someone on your behalf pays for your services in full.
Example: If you receive certain medical devices, you may refuse to release your name, address, telephone number, social security number, or other identifying information used for tracking the medical device.
Out of Pocket Payments
If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or healthcare operations, and we will honor that request.
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. We must accommodate reasonable requests.
Example: You may request to be contacted at a phone number that is different from the phone number listed in your health care record.
Inspect and Obtain a Copy of Your Health Record
With few exceptions, you have the right to inspect and obtain a copy of your health care record. You have the right to request that the copy is provided in an electronic form or format (e.g., PDF saved onto a CD). 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. Your request for access to your health care record must be submitted in writing to Wascher Cervical Spine Institute. This right may not apply to certain types of psychotherapy notes. In addition, we may charge you a reasonable fee for a copy of your health care record.
Example: You may request a copy of your immunization record from your health care provider.
Amend Your Health Record
If you believe your health information is incorrect or incomplete, you may ask us to correct the information. You may be asked to make this request in writing and state the reason why your health record should be changed. 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.
Example: If you believe that information in your medical history is incorrect, such as your birth date, you may request that this information is amended.
Obtain an Accounting of Disclosures of Your Health Information
You have the right to request an accounting of disclosures of your health information that we have made in compliance with state and federal law. The accounting will list the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and the reason for disclosure. We must comply with your request for a list within 60 days unless you agree to a 30-day extension. You will receive one accounting per year at no charge; we may charge you a reasonable fee for each subsequent request.
Example: You may request an accounting of disclosures made from your health record in the last year to the state for disease reporting.
Obtain a Paper Copy of This Notice
Upon your request, you may at any time obtain a paper copy of the notice, even if you earlier agreed to receive this notice electronically. The website is wascherspineinstitute.com.
Example: If you received the notice electronically, you may request that Wascher Cervical Spine Institute provide a paper copy of the notice.
Notified of a Breach
We are 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.
Patient Complaint Process
If you believe your privacy rights have been violated, you may file a complaint with us with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint. To file a complaint with us, or the Secretary of the Department of Health and Human Services please contact the Wascher Cervical Spine Institute’s Privacy Officer. All complaints must be made in writing and should be submitted 180 days of when you knew or should have known of the suspected violation.
Treatment
We may disclose your health care information in the provision, coordination or management of your healthcare. Our communication to you may be in person, by phone, mail, fax or electronically to physicians, nurses, technicians, or other personnel who are involved in your care or treatment. 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.
Example: We may use your information to call and remind you of an appointment or to refer your care to another physician.
Payment
We may use or disclose your health care information to obtain payment for your health care services.
Example: we may provide the information to your health plan to obtain payment for the provision of the health care services.
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.
Example: We may use your information to determine the quality of care you received when you had your surgery.
As Required by Law
We may disclose your health information to the extent that the use or disclosure is required by law.
Example: We may disclose medical information to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
Public Health
We may disclose your health information to the 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 (FDA).
Worker’s Compensation
We may disclose your health information to the appropriate persons in compliance with workers’ compensation laws.
Example: We may provide information about your work-related injury to your employer.
Victims of Abuse, Neglect or Domestic Violence
We may disclose your health information to health agencies authorized by law to receive reports of abuse, neglect or violence related to children or the elderly.
Health Oversight Activities
We may disclose your health information to agencies authorized by law to conduct audits, investigations, inspections, licensure and other proceedings related to oversight of health care systems or government benefit programs.
Judicial and Administrative Proceedings
We may disclose your health information 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.
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.
Activities Related to Death
We may use or disclose your health information to coroners, medical examiners, and funeral directors so they can carry out their duties related to death, such as identifying the body, determining the cause of death, or in the case of funeral directors, to carry out funeral preparation activities.
Example: We may use or disclose your HIV test result to a funeral director.
Cadaver Organ, Eye or Tissue Donation Purposes
We may use or disclose your health information to people involved with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.
Research
We may use or disclose your health information to conduct research only under certain circumstances and after a special approval process.
Example: A research project may involve comparing a certain treatment to another to see which is working better.
To Avoid a Serious Threat to Health or Safety
We may disclose your health information in a very limited manner to appropriate persons if we believe, in good faith, that such disclosure is necessary to prevent or minimize a serious threat a serious threat to the health or safety of a particular person or the general public.
Example: We may disclose your health information to the Department of Transportation (DOT) if your medical condition affects your ability to safely drive a car.
Specialized Government Functions
We may disclose your health information under certain and very limited circumstances for the military, national security, or law enforcement custodial situations.
Communications with You
We may use or disclose your health information to provide information to you regarding your test results, remind you of appointments, recommend treatment alternatives or wellness services that may be of interest to you, or provide you with surveys regarding your care.
Shared Medical Record/Health Information Exchange
We may maintain your health information in a shared electronic medical record. Unless you object, we may also submit your health information to an electronic health information exchange (HIE). Participation in a HIE allows us and other providers to see and use information about you for your treatment, payment and health care operations.
Facility Directory
Unless you object, we may use your health information, such as your name, location in our facility, your general health condition, 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 director 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:
Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you.
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 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 disclosure we have already made with your permission.
If you have any questions or concerns regarding your privacy right or the information in this notice, please contact:
Privacy Officer Wascher Cervical Spine Institute 5320 West Michaels Drive Appleton, WI 54913 (855) 854-9274
