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NOTICE 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 IT CAREFULLY. THE PRIVACE OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

EFFECTIVE DATE: April 18, 2017

OUR LEGAL DUTY

We are required by applicable federal and state laws to maintain the privacy of your protected health information (‘PHI’). We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your PHI. We are required to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices described in this notice while it is in effect. This notice will remain in effect until we replace it.

We reserve the right make the changes in our privacy practices provided that such changes are permitted by applicable law and the new terms are effective for all protected health information that we maintain, including medical information we created or received before we made the changes. We will provide you with a revised notice in person during your next office visit. You may also request a copy of our notice (or any subsequent revised notice) at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

USES AND DISCLOSURES WITHOUT YOUR WRITTEN AUTHORIZATION:

We may use and disclose your PHI about you for treatment, payment, and health care operations. Following are examples of the types of uses and disclosers of your protected health care information that may occur. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment: We may use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party or to other physicians who may be treating you. For example, we would disclose your PHI to other physicians in order to diagnose or treat you. In addition, we may disclose your PHI from time to time to another physician or health care provider (e.g. specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Health Care Operations: We may use disclose, as needed, your PHI in order to conduct certain business and operational activities. These activities include, but are not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when your doctor is ready to see you.

We may share your PHI with third party “business associates” that perform various activities (e.g. billing, transcription services) for the practice. Whenever an arrangement between our office and a business associates involves the use or disclose of your PHI, we will have a written contact that contains terms that will protect the privacy of your PHI.

We may use or disclose your PHI, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use and disclose your PHI for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. In order to receive this information, we are required to obtain an authorization from you. Should you not wish to receive these marketing materials, you may opt out on the authorization.

USES AND DISCLOSURES BASED ON YOUR WRITTEN AUTHORIZATION:
  1. Research; Death; Organ Donation: We may use or disclose your protected health information for research purposes in limited circumstances. We may disclose the protected health information of a deceased person to a coroner, protected health examiner, funeral director, or organ procurement organization for certain purposes.
  2. Public Health and Safety: We may disclose your protected health information to the extent necessary to avert a serious and imminent threat to your health or safety, or the health or safety of others. We may disclose your protected health information to a government health agency authorized to oversee the health care system or government programs or its contractors, and to public health authorities for public heath purposes.
  3. Health Oversight: We may disclose protected health information to the extent necessary to avert a serious and imminent threat to your health or safety, or the health or of others. We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
  4. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
  5. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations; to track products to enable product recalls; to make repairs or replacements; or to conduct post marketing surveillance, as required.
  6. Criminal Activity: Consistent with applicable state and federal laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend and individual.
  7. Required by Law: We may use or disclose your protected health information when we are required to do so by law. For example, we must disclose your protected health information to the U.S Department of Health and Human Services upon request for purposes of determining whether we are in compliance with privacy laws. We may disclose your protected health information when authorized by workers’ compensation or similar laws. We may disclose your protected health information in response to a court or administrative order, subpoena, discovery request or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant or grand jury subpoena, we may disclose your protected health information to law enforcement officials.
  8. Fugitive, material witness, crime victim, or missing person: We may disclose protected health information of an inmate or other person in lawful custody to a law enforcement official or correctional institution under certain circumstances. We may disclose protected health information where necessary to assist law enforcement officials to capture an individual who has admitted to participation in a crime or has escaped from lawful custody.
  9. Specialized Government activities: We may disclose your protected health information for military, national security, and prisoner purposes.
YOUR PROTECTED HEALTH INFORMATION RIGHTS:
  1. Access: You have the right to look at or get copies of your protected health information, with limited exceptions. You may request electronic copies of your protected health information contained in electronic health records or you may request in writing or electronically that another person receive an electronic copy of your records. If you request a copy of your electronic records, it will be provided in the format requested or in a mutually agreed-upon format. We may charge you for the cost of any electronic media (such as a USB flash drive) used to provide a copy of the electronic PHI. You must make a request in writing to the contact person listed herein to obtain access to your protected health information. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you in accordance with applicable state law. If you prefer, we will prepare a summary or explanation of your protected health information for a fee. Contact us using the information listed at the end of this notice for a full explanation of our fee structure. We may disclose your protected health information following your death to a family member or close personal friend who was involved in your care or payment prior to your death, however, we will not disclose any information if we are aware that you would not have wanted disclosure of your protected health information.
  2. Accounting of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your protected health information for the purpose other than treatment, payment, health care operations and certain other activities after April 14, 2003. After April 14, 2003, the accounting will be provided for the past six (6) years. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your protected health information, a description of the protected health information we disclosed, the reason for the disclosure, and certain other information. If you request this list more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contacts us using the information listed at the end of this notice for a full explanation of our fee structure.
  3. Restriction Requests: YYou have the right to request that we place additional restrictions on our use or disclosure of your protected health information. If you pay for a service entirely out-of-pocket, you may request that information regarding the service be withheld and not provided to a third party payor for purposes of payment or health care operations. We are obligated by law to abide by such restriction. Otherwise, we are not required to agree to additional restrictions requests, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is so memorialized in writing.
  4. Confidential Communication: You have the right to request that we communicate with you in confidence about your protected health information by alternative means or to an alternative location. You must make your request in writing. We must accommodate your request if it is reasonable, specifies the alternative means or locations, and continue to permit us to bill and collect payment from you.
  5. Amendment: You have the right to request that we amend your protected health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended or for certain other reason. If we deny your request, we will provide you a written explanation. You may respond with a information, we will make reasonable efforts to inform others, including people or entities you name, of the amendment and to include the changes in any future disclosures of the information.
  6. Right to Restrict Disclosure to a Health Plan: You have the right to restrict that we not share your protected health information with a health plan for payment or operations purposes if the protected health information relates to services for which you paid in full.
  7. Electronic Notice: If you receive this notice on our website or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain the notice in written form.
  8. Notice of Breach: You have a right to notification if we discover a breach of any of your PHI that is not secured in accordance with federal guidelines.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us using the information below:

If you believe that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI or in response to a request you made, you may complain to us using the contact information below. You also may submit a written complaint to the U.S Department of Health and Human Services upon request.

We support your right to protect the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S Department of Health and Human Services.

Name of Contact Person: Lauren V. Moes
Telephone: (262) 242-7772
Email: legal@myquintessa.com
Mailing Address: 10604 N. Port Washington Rd. Mequon, WI 53092