This notice describes how private medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We care about your privacy!
To provide you with quality services, we need to collect private information from you. That information stays in our agency and is not shared with others unless necessary.
Sometimes we will ask your written permission to use or share your private information with another person, agency, or treatment facility. This is done so that we can give you the best services and treatment possible. If you give us permission to use or share your private information, you may also change your mind at any time and cancel your authorization by writing to us.There are some situations where we do not ask for your written permission to use or share your private information. These are limited and for the following purposes…
- Treatment. For example, our doctor may use the information in your file to determine which medication would be best for you.
- Payment. For example, we need to give insurance companies your identifying information with your diagnosis and treatment so that we can be paid.
- Health care operations. For example, we may use information in your file to decide the date of your next appointment and then call you to remind you; or we may use your diagnosis, treatment, and outcome to improve the quality of services; or your file may be reviewed by financial auditors or clinic certifiers.
- As required or permitted by law. Sometimes we must report some of your private information to legal authorities, such as law enforcement officials or other government agencies. For example, we may disclose your private health information…
- to agencies involved in health oversight activities, for example audits, clinic certification, investigations, or inspections
- to a coroner, medical examiner, or funeral director to carry out their dutiesto social service agencies to report abuse, neglect, or domestic violenceto the Food and Drug Administration (FDA) to report reactions or problems with medications
- to military, national security, correctional authorities, or other law enforcement officials to carry out their duties
- For public health activities. We may be required to report certain health information to public health departments to help prevent or control disease, injury, or disability.
- Disaster relief efforts. We may disclose health information to an agency helping in a disaster relief effort so that your safety and health can be assured.
- Avert a serious threat to health or safety. We may use or disclose health information about you when necessary to try to prevent a serious threat to the health or safety of you, another person, or the public.
You also have rights about your private information. Specifically you have the right to…
- Access your private information. With a few exceptions, you have the right to look at and get a copy of your private information. You may be charged a reasonable fee for copying and mailing costs. This right does not apply to psychotherapy notes, information gathered for judicial proceedings, or information from other sources.
- Correct your private information. If you believe your private information is incorrect, you may ask us to correct the information. You must make this request in writing and tell us why it should be changed. If we disagree with you and believe our information is correct, we may deny your request and not change your private information. If we don’t agree, we will notify you in writing.
- Restrict the use and sharing of your private information. You have the right to ask for restrictions on how your private information is used or to whom your information is shared. For example, you can limit the information provided to family or friends even if they provide care or pay for services; or you can also limit the information shared to authorities involved with disaster relief efforts. However, we may not agree with your requested restrictions. If we don’t agree, we will notify you in writing.
- Receive confidential communication of your private information. You can ask us to communicate to you in different ways or places. For example, you may want to hear about your health information in a private room or through a written letter sent to a private address. You will be asked how you want to receive appointment reminders. We will accommodate all reasonable requests.
- Receive a list of who was given your private information and why. Starting April 14, 2003, you may ask for this list of disclosures of your private information we have made for the past six years. Within 60 days of your request, we will give you a list of disclosures. This list is free unless you request it more than once a year. This list does not include disclosures made to you or for purposes of treatment, payment, health care operations, national security, law enforcement/corrections, and certain health oversight activities.
- Receive this notice. At any time, you may request a copy of our Privacy Notice.
- File a complaint. If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer and/or the federal Department of Health and Human Services. You will not be penalized for filing a complaint.
We may have to change our privacy practices. We reserve the right to make such changes effective for all private information we may already have about you. If we change our privacy practices, we will post a copy of the revised Privacy Notice in our office. We will also give you a copy of the revised policy if you ask.
If you have any questions about this notice, wish to withdraw an existing authorization to release private information, want to file a complaint, or want to exercise your privacy rights in other ways, contact our Privacy Officer. You can call our Privacy Officer at 715-273-6766 or write to P.O. Box 670; 412 West Kinne Street; Ellsworth, WI 54011.
This Privacy Notice is effective April 14, 2003.
Receipt of Privacy Notice
By signing this form you agree that Pierce County Department of Human Services has given you a copy of their Privacy Notice and given you the chance to discuss your concerns and questions about privacy. The Privacy Notice explains how your private information will be handled in various situations. Receipt of this notice is required on the first day of service. If your first date of service was due to an emergency, you will be given the notice as soon as possible after the emergency.Printed Client name: ________________________________ Date of birth: ____________
Client Signature: ___________________________________ Date: ___________________