NOTICE OF PRIVACY PRACTICES
REGARDING YOUR HEALTH INFORMATION
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.
Washington County is required by law to maintain the privacy of your protected health information. This information consists of all records related to your health, including demographic information, either created by Washington County or received by Washington County from other health care providers.
We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. Washington County will abide by the terms of this Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information.
Washington County reserves the right to change the terms of this Notice and to make any new provisions effective for all protected health information that we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time.
Uses and Disclosures of Your Protected Health Information not Requiring Your Consent:
Washington County may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment and healthcare operations. There are certain restrictions on uses and disclosures of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence. There are also restrictions on disclosing HIV test results.
These examples are not meant to be exhaustive:
Treatment may include:
- Providing, coordinating, or managing health care and related services by one or more health care providers.
- Consultations between health care providers concerning a patient.
- Referrals to other providers for treatment
- Referrals to nursing homes, foster care homes, or home health agencies
For example, Washington County may determine that you require the services of a specialist. In referring you to another doctor, Washington County may share or transfer your healthcare information to that doctor.
Payment activities may include:
- Activities undertaken by Washington County to obtain reimbursement for services provided to you.
- Determining your eligibility for benefits or health insurance coverage.
- Managing claims and contacting your insurance company regarding payment;
- Collection activities to obtain payment for services provided to you;
- Reviewing health care services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under your health plan, appropriateness of care, or justification of charges;
- Obtaining pre-certification and pre-authorization of services to be provided to you.
For example, Washington County will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided to you.
Healthcare operations may include:
- Contacting health care providers and patients with information about treatment alternatives;
- Conducting quality assessment and improvement activities;
- Conducting outcomes evaluation and development of clinical guidelines;
- Protocol development, case management, or care coordination;
- Conducting or arranging for medical review, legal services and auditing functions.
For example, Washington County may use your diagnosis, treatment, and outcome information to measure the quality of the services that we provide or assess the effectiveness of your treatment when compared to patients in similar situations.
Washington County may contact you, by telephone or mail, to provide appointment reminders.
You must notify us if you do not wish to receive appointment reminders.We may disclose your protected health information to family members or friends who may be involved with your treatment or care or payment for your care without your written permission, if we believe that it is in your best interest. Health information may be released without written permission to a parent, guardian, or legal custodian of a minor child; the guardian of an incompetent adult; the healthcare agent designated in an incapacitated patient’s healthcare power of attorney; or the personal representative, domestic partner or spouse of a deceased patient.
There are additional situations when Washington County is permitted or required to use or disclose your protected health information without your consent or authorization. Examples include the following:
As permitted or required by law
In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries.We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe that the wound occurred as a result of a crime.Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on the premises of an inpatient treatment facility or nursing home.We will share information with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
For public health activities
We may release healthcare records, with the exception of treatment records, to certain government agencies or public health authority authorized by law, upon receipt of written request from that agency. We are required to report positive HIV test results to the state epidemiologist. We may also disclose HIV test results to other providers or persons when there has been or will be risk of exposure.We may report to the state epidemiologist the name of any person known to have been significantly exposed to a patient who tests positive for HIV. We are required by law to report suspected child abuse and neglect and suspected abuse of an unborn child, but cannot disclose HIV test results in connection with the reporting or prosecution of alleged abuse or neglect. We may release healthcare records, including treatment records and HIV test results, to the Food and Drug Administration when required by federal law. We may disclose healthcare records, except for HIV test results, for the purpose of reporting elder abuse or neglect, provided the subject of the abuse or neglect agrees, or if necessary to prevent serious harm. Records may be released for the reporting of domestic violence if necessary to protect the patient or community from imminent and substantial danger.
For health oversight activities
We may disclose healthcare records, including treatment records, in response to a written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification. HIV test results may not be released to federal or state governmental agencies, without written permission, except to the state epidemiologist for surveillance, investigation, or to control communicable diseases.
Judicial and Administrative Proceedings
Patient healthcare records, including treatment records and HIV test results, may be disclosed pursuant to a lawful court order. A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records except for HIV test results.
For activities related to death
We may disclose patient healthcare records,except for treatment records, to a coroner or medical examiner for the purpose of completing a medical certificate or investigating a death. HIV test results may be disclosed under certain circumstances.Washington County may share health information about you with an organ procurement organization.
For research
Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.
To avoid a serious threat to health or safety
We may report a patient’s name and other relevant data to the Department of Transportation if it is believed the patient’s vision or physical or mental condition affects the patient’s ability to exercise reasonable or ordinary control over a motor vehicle. Healthcare information, including treatment records and HIV test results, may be disclosed where disclosure is necessary to protect the patient or community from imminent and substantial danger.
For workers’ compensation
We may disclose your health information to the extent such records are reasonably related to any injury for which workers compensation is claimed.
Washington County will not make any other use or disclosure of your protected health information without your written authorization. You may revoke such authorization at any time, except to the extent that Washington County has taken action in reliance thereon. Any revocation must be in writing.
Your Rights Regarding Your Protected Health Information
You have several rights with regard to your protected health information. Uses and disclosures made for the purpose of psychotherapy, marketing and the sale of protected health information require your authorization.The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise your rights.
- Right to Inspect and Copy Your Protected Health Information
You have the right to inspect and to request a copy of information maintained in our designated medical record about you. This includes medical and billing records maintained and used by us to make decisions about your care. To obtain or inspect a copy of your medical record information, contact the records department at the location you had services. We may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.You have the right to obtain an electronic copy of your medical information if you choose. You may direct us to transmit the copy to another entity or person that you name provided that the request is made in writing, signed by you and clearly identifies the designated person and where to send the copy of the protected health information.We may charge a fee for the labor costs needed to provide the electronic copy. 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.Most clients have full access to inspect and receive a copy of their full medical record. On rare occasions, we may deny a request to inspect and receive a copy of some information in the medical record. This includes psychotherapy notes or information gathered for judicial proceedings or if, in the professional judgment of your physician, the release of the information would be reasonably likely to endanger the life or physical safety of the client or another person.
- Right to Request to Change Your Protected Health Information
You have the right to request that we amend the information in your record, if you believe the information is incomplete or incorrect. You will need to tell us why your protected health information should be changed. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment form and include the amendments in any future disclosures of that information. We may deny your request if we did not create the information you want amended, the information is already accurate and complete, the originator is no longer available to make the amendment or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement, which may be added to the information you wanted changed.
- Right to Request Restrictions on Certain Uses and Disclosures
You have the right to request that we limit how your health information is used or disclosed for treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your request must be in writing. We are not required to agree in all circumstances to your requested restriction.If we agree to your request, we will abide by our agreement (except in any emergency or when the information is necessary to treat you). You may cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation. We are required to agree to prevent disclosure of your health information to a health plan for the purpose of carrying out payment or health care operations, but only if it pertains solely to a health care item or service which has been paid out-of-pocket and in full. This restriction does not apply to use or disclosure of your health information related to your medical treatment.
- Right to Receive Confidential Communications of Protected Health Information
You have the right to ask that we communicate your health information to you in different ways or places. For example, you may wish that information about your health status be sent to a private address or discussed in a private area. We will accommodate reasonable requests. We will require that you provide an alternative address or other method of contact and how payment will be handled. If requesting confidential communication, you must ask in writing.
- Right to Receive an Accounting of Disclosures of Your Protected Health Information
You have the right to request a list of the disclosures of your health information that we have made in compliance with federal and state law. This list will include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed and why the disclosure was made. For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made.We will include all the disclosures except for those about treatment, payment and healthcare operations.
For example, you may request a list that indicates all the disclosures your health care provider has made from your record in the past six months. We must comply with your request for a list of disclosures within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request a list more than once a year.
- 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 agreed to receive this notice electronically. A paper copy of this Notice will be provided to you when you first start services with us and will be available at our office.Even if you have received a copy of this Notice before, you may still be asked to sign that you have received this Notice.
- Right to Receive Notice of Breach
We are required by law to maintain the privacy of protected health information and to notify you by first class mail of any breach of your unsecured protected health information.
Complaints
Any person or patient may file a complaint with Washington County and/or the U.S. Department of Health and Human Services Office for Civil Rights if they believe their privacy rights have been violated. To file a complaint with Washington County, please contact the Privacy Officer or the HIPAA Contact Person at the following:
Privacy Officer –Bradley S. Stern
Washington County Government Center
432 E. Washington Street, Suite 3029
West Bend, WI 53095
Phone: 262-335-4374
HIPAA Contact Person for Samaritan Health Center:
Sara Roell
531 E. Washington Street
West Bend, WI 53095
Phone: 262-335-4539
HIPAA Contact Person for Human Services Department:
Julie Driscoll
333 E. Washington Street, Ste. 2100
West Bend, WI 53095
Phone: 262-335-4591
HIPAA Contact Person for Health Department:
Kim Buechler
333 E. Washington Street, Ste. 1100
West Bend, WI 53095
Phone: 262-335-4470
HIPAA Contact Person for Human Resources:
Todd Scott
432 E. Washington Street, Ste. 3024
West Bend, WI 53095
Phone: 262-335-4330
HIPAA Contact Person for Washington County Jail
Sergeant John Julson
484 Rolfs Road
West Bend, WI 53095
Phone: 262-335-6862
Security Officer for Washington County:
Information Services
Joel Woppert
432 E. Washington Street
West Bend, WI 53095
Phone: 262-335-6869
It is the policy of Washington County that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance or violation of the privacy standards.
This Notice of Privacy Practices is effective April 14, 2003.
Amended 12-17-04
Amended 09-23-13