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

OUR PROMISE TO YOU, OUR PATIENTS

Your information is important and confidential.

Our ethics and policies require that your information be held in strict confidence.

Questions or Concerns

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:

Privacy Officer

DeFatta Health

1490 Rivers Edge Tr Altoona WI 54720

715-828-2368 or (844) 346-9368

Effective April 15, 2014

Understanding Your Health Record

Each time you visit DeFatta Health, a record of your visit is made. Typically, this record contains your demographic information, symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care & treatment,
• Means of communication among the health professionals who contribute to your care,
• Legal document describing the care you received,
• Means by which you or a third-party payer can verify that services billed were actually provided.

Understanding what is in your record and how your health information is used helps you to better understand who, what, when, where, and why others may access your health information and to make more informed decisions when authorizing disclosure to others.

Protecting Your Privacy

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. This Notice is effective April 15, 2014, and applies to all protected health information as defined by federal regulations.

Our Responsibilities

DeFatta Health is required to:

• Maintain the privacy of your health information,
• Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; and
• Abide by the terms of this notice

We reserve the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information we maintain. We also reserve the right to change the terms of this notice with respect to any applicable more limited uses and disclosures. We will promptly revise and distribute our notice whenever we make a substantial change to any of our privacy practices. We will keep a posted copy of the most current notice in our facility containing the effective date in the bottom, right-hand corner. In addition, each time you visit our facility for treatment, you may obtain a copy of the current notice in effect upon request. We will not use or disclose your health information without your authorization, except as described in this notice. It is our responsibility to notify you if there is a breach of confidentiality.

Your Health Information Rights lii

Although your health record is the physical property of DeFatta Health the information belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your protected health information, even if the restriction affects your treatment, payment or health care operation activities. However, we are not required by law to agree to a requested restriction.
  • For example, if you are an employee of the clinic and you receive health care services in the clinic, you may request that your health care record not be maintained in the general record filing area.
• Request confidential communications by alternative means or at alternative locations. This request must be submitted in writing. We shall accommodate reasonable requests.
  • For example, you may request to be contacted at a phone number that is different from the phone number listed in your healthcare record.
• Inspect and obtain a copy of your health care record. This request must be submitted in writing to our staff. We may charge you a reasonable fee for a copy of your health care record.
• Request an amendment to your health care record if you believe your health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health care record should be changed. If we disagree with you, we may deny your request.
  • For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended.
• Obtain an accounting of disclosures of your health information that we have made in compliance with state and federal law, beginning with disclosures made after April 15, 2014. The accounting will describe the dates of each disclosure, a brief description of information disclosed, and the reason for disclosure.
  • For 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 of privacy policies upon request.
  • For example, if you received the notice electronically, you may request that we provide a paper copy of the notice.

Uses and Disclosures for Treatment, Payment, and Health Organizations

We are permitted by the federal privacy rule to use or disclose your health information, without your written consent or authorization, for certain treatment, payment, or health care operations.

We may use or disclose your health information in the provision, coordination or management of your health care.

For example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment. We will also provide your other physician(s) or subsequent health care provider(s) (when applicable) with copies of various reports that should assist them in treating you and to ensure continuity of care.

We may use or disclose your health information to obtain reimbursement for health care services provided to you.

For example: Your information may be used or disclosed to your insurer to obtain payment for the provisions of health care services.

We may use or disclose your health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.

For example: Your information may be used or disclosed to measure the quality of the services we provide, or assess the effectiveness of your treatment when compared to patients in similar situations.

Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization

Without your written authorization, we may use or disclose your health information for the following purposes:

• As Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses and disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:
  • Disclosures about victims of elderly or child abuse;
  • Disclosures for judicial and administrative proceedings; or
  • Disclosures for law enforcement purposes.
• Public Health: As required by law, we may disclose your health information to the State of Wisconsin for the purpose of statutory reporting.
• Judicial and Administrative Proceedings: We may disclose your protected health information in response to a court order.
• Law Enforcement: We may disclose your protected health information to county law enforcement officials for the reporting and investigation of elderly and/or child abuse or in response to a court order.
• Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• Research: We may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.
• Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
• Workers Compensation: We may disclose protected health information that is reasonably related to a work related illness or injury if an application for workers’ compensation has been filed.
• Appointment Reminders: We may contact you or a family member at the phone number you have provided to us as a reminder that you have an appointment.
• Marketing: We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
• Notification: We may use or disclose information to notify or assist in notifying a family member or personal representative (or other person responsible for your care) of your location and general condition.
• Communication: Health professionals, using their best judgment, may disclose to a family member, other relative, or close personal friend (or any other person you identify) health information relevant to that person’s involvement in your care or payment related to your care.

Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your health information requires DeFatta Health to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to DeFatta Health.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you. If you pay out-of pocket in full for an item or service, then you may request that we not disclose information pertaining solely to such item or service to your health plan for purposes of payment or health care operations. We are required to agree with such a request, unless you request a restriction on the information we disclose to a health maintenance organization (“HMO”) and the law prohibits us from accepting payment from you above the cost-sharing amount for the item or service that is the subject of the requested restriction. However, we are not required to agree to any other request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or you request that we remove the restriction.

For More Information or To Report a Problem

If you believe your privacy rights have been violated, you may file a complaint with DeFatta Health or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint.

Changes to This Notice

The effective date of this notice is April 15, 2014, and it has been updated effective April 6th, 2020. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. If the terms of this notice are changed, DeFatta Health will provide you with a revised notice upon request, and we will post the revised notice on our website and in designated locations at our clinic.