Wisconsin Surgery Center

JOINT NOTICE OF PRIVACY PRACTICES AND PATIENT RIGHTS

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

When we refer to “you” or “your” in this Notice, we refer to the patient. When we refer to disclosures of information to “you,” we mean disclosures to the patient, the patient’s parent, guardian or other person legally authorized to receive information about the patient.

Who follows this Notice:

This Notice applies to all patient health information maintained by Wisconsin Surgery Center(“Facility”) for services provided at 3305 South 20th Street, Suite 150, Milwaukee, WI 53215.

If you have any questions after reading this Notice, please contact the Facility’s Privacy Officer.

Each time you visit the Facility, your physician or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and billing-related information.

Responsibilities

• Each visitor is responsible to be considerate of others by observing safety and smokingregulations at the facility.
• Each visitor is responsible to be considerate of Wisconsin Surgery Center personnel.
• Each patient is responsible to supply accurate and complete history information.
• Each patient is responsible to make follow-up appointments with the surgeon as directed.
• Each patient is required to provide complete and accurate information to the best of his/her ability about his/her health, and medications, including over-the-counter products and dietary supplements and any allergies or sensitivities.
• Each patient is required to provide a responsible adult to transport him/her home from the facility and remain with him/her for twenty-four (24) hours, if required by his/her provider.
• Each patient is required to inform his/her provider about and living will, medical power of attorney, or other directive that could affect his/her care.
• Each patient is responsible to inform Wisconsin Surgery Center personnel if their instructions, information, or answers to your questions are unclear of impossible to follow.
• Each patient is responsible to fulfill any financial obligations you may incur.
• Each patient is required to follow the treatment plan described by his/her provider.

Patient’s Bill of Rights and Responsibilities

Wisconsin Surgery Center is committed to providing comprehensive healthcare in a manner which acknowledges the uniqueness and dignity of each patient. We encourage patients and families to have clear knowledge of and participate in matters and decisions relating to the medical care provided.

Rights

• You have the right to be treated with respect, consideration and dignity.
• You have the right to privacy when receiving care and to have your medical records held in confidence. You have the right to approve or refuse the release of these records.
• You have the right to receive care in a safe setting and be free from harassment or abuse.
• You have the right to voice grievances of treatment and care.
• You have the right to change providers if other qualified providers are available.
• You have the right to participate in decisions regarding your healthcare and to complete information regarding your condition, prognosis and treatment.
• You have the right to be informed of the expected outcome before the procedure.
• You have the right to consult with other health professionals when you feel such a consultation is necessary.
• You have the right to consent to, or refuse involvement in medical studies or research projects conducted by Wisconsin Surgery Center.
• You have the right to be informed of business relationships between Wisconsin Surgery Center and other healthcare providers, insofar as your care is concerned.
• You have the right to be informed of policies or regulations by which you are expected to abide.
• You have the right to exercise your rights without being subjected to discrimination or reprisal

Right to Revoke Authorization

Uses and disclosures of health information not covered by this Notice or the laws that apply to the Facility will be made only with your authorization. If you authorize the Facility to use or disclose your health information, you may revoke that authorization in writing at anytime. We are unable to take back any disclosures we have already made with your permission. To revoke an authorization you must contact the Medical Records

Right to Complain

If you believe your privacy rights have been violated, you may file a complaint with the Facility or with the Secretary of the Department of Health and Human Services. To file a complaint with the Facility, contact the Privacy Officer. All complaints must be made in writing. The Privacy Officer will assist you in filing your complaint and the necessary paper work. Filing a complaint will not affect your care and treatment.

Important Note: We reserve the right to revise or change this Notice. Each time you sign a consent for treatment at a site covered by this Notice, we will provide you with a copy of the Notice in effect at that time. The rights of any patient, adjudged incompetent under applicable state health and safety laws by a court of the proper jurisdiction, will be exercised by the person appointed under state law to act on the patients behalf

This Notice applies to all of the records of you rcare generated by the Facility whether made by Facility employees, agents or your physician may have different policies or notices regarding the physician’s use and disclosure of your health information created in the physician’s private office.

Our Pledge to Protect Your Health Information

We are required by law to maintain the privacy of your health information and provide you with this description of our privacy practices. We will abide by the terms of this Notice.

How We May Use, and Share Your Health Information With Others

For Treatment

We will use health information about you to provide you with medical treatment or services. We will disclose health information about you to doctors, residents, nurses, technicians, students in health care training programs, or to Facility personnel who are involved in taking care of you. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes might slow the healing process. Different departments of the Facility also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside the Facility who provide your medical care after you leave the Facility. For example, a physician that provides your care following your surgery will be provided information about your care and treatment here.

For Payment

The Facility will use and disclose your health information to send bills and collect payment from you, your insurance company, or other payors, such as Medicare and Medicaid, for the care, treatment and other related services you receive from the Facility. We also may provide your name, address, health care and insurance information to other care providers (for example, your physician) related to your care at the Facility. We also may tell your health insurer about a treatment your physician has recommended in order to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations

We may use and disclose health information about you for Facility business operations. These uses and disclosures are necessary to run the Facility and make sure that all of our patients receive quality care and cost-effective services. For example, we may use health information to review the quality of our treatment and services and to evaluate our performance in caring for you. We also may combine our health information with health information from other hospitals for our staff and students to improve our care and services. In these instances, we remove information that identifies you as an individual from your health information. When we use or disclose your health care information, it may be to another organization that assists us in operating our Facility. For example, when your physician dictates a summary of his or her visit with you, an outside company types up the document for our medical records. We have contracted with these outside agencies, who are called “business associates,” to keep any health care information received from us confidential.

Appointments

The Facility may contact you for appointments. Messages left for you will not contain specific health information.

Required or Permitted By Law

The Facility is required by law to disclose your health information in certain circumstances to:

• Control or prevent a communicable disease, injury or disability, to report births and deaths, and for public health oversight activities or interventions.
• The Food and Drug Administration (FDA), to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law.
• A state or federal government agency to facilitate their functions.
• Report suspected elder or child abuse to law enforcement agencies responsible to investigate or prosecute abuse.
• Respond to a valid court order.
• The Department of Health and Family Services (DHFS), a protection or advocacy agency or law enforcement authorities investigating abuse, neglect, physical injury, death, violent crimes involving suspicious wounds, burns, gunshot wounds or death.
• Work with a medical examiner or funeral director. We can share health information with a coroner, medical director, or funeral director when an individual dies.
• Your court-appointed guardian or an agent appointed by you under a health care power of attorney.
• Prison officials if you are in custody.
• Worker’s Compensation officials if your injury or illness is work-related.

Organ, Eye, and Tissue Donation

The Facility will disclose health information to organizations that obtain, bank, or transplant organs, eyes or tissue.

Research

Under certain circumstances, the Facility may use and disclose your health information for research purposes. For example, a research project might compare the health and recovery of all patients who received one medication to those who received another for the same condition. For this type of project, a privacy board may waive the need for consent and any published results would not include information that identifies you. In other circumstances, you will be asked to give consent to participate in a research project. You may choose not to participate in research. Your care and treatment will not be affected by your decision. When sharing information with others outside the Facility, we share only what is reasonably necessary unless we are sharing information to help treat you, in response to your written permission, or as the law requires. In these cases, we share all the information that you, your health care provider, or the law has requested.

YOUR HEALTH INFORMATION RIGHTS

Right to Request Restrictions

You have the right to request certain restrictions of the Facility’s use or disclosure of health information for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your health information to someone who is involved in your care or the payment for your care. The Facility is not required to agree to your request if it interferes with patient care, treatment, Facility operations, and/or payment of your bill. If the Facility does agree to the restrictions, it will comply with your request unless the information is needed to provide you with emergency treatment. A request for restriction must be made in writing. To request a restriction you must complete a request form that is available in patient care areas or in the Medical Records Department.

Right to Inspect and Copy

You have the right to inspect and receive copy of your health records. For copies of your health information, requests must go to the Medical Records Department. For billing information, contact Patient Financial Services.

Right to Amend

If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is maintained by the Facility. Requests for amending your health information should be made in writing to the Medical Records Department. The Facility will respond to your request within 60 days after you submit the written amendment request form. Right to an Accounting of Disclosures You have a right to request an “accounting of disclosures.” This is a list of those people with whom the Facility may have shared your health information, with the exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. To request an accounting of disclosures, you must submit your request in writing to Medical Records Department. We will provide the list at no cost once during each 12-month period. For any additional requests, we may charge you a fee for the cost of providing the list. We will notify you of the fee and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Confidential Communications

You have the right to request that we communicate with you about your health information in a certain way or at a certain location. For example, you can ask that we contact you only at work or by mail. We will accommodate all reasonable requests.