DIVISION OF ENTERPRISE SERVICES 1 WEST WILSON STREET P.O. BOX 7850 MADISON WI 53707-7850
Jim Doyle Governor
Karen E. Timberlake Secretary
State of Wisconsin Department of Health Services
Telephone: 608-266-8445 FAX: 608-267-6749 TTY: 888-701-1251 dhs.wisconsin.gov
NOTICE OF 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.
Effective Date: April 14, 2003 The treatment facilities of the Wisconsin Department of Health Services (DHS) are committed to protecting the privacy of your medical information. These facilities are listed at the bottom of this page. This Notice of Privacy Practices explains how we may use or release your medical information and outlines your privacy rights. Medical information used or released may include information that appears on treatment, payment, and other records used to make decisions about you in the course of providing care, services, or other benefits.
Spanish Si necesita ayuda para traducir o entender este texto, por favor llame al teléfono 1-800-362-3002 (V/TTY) Russian , 1-800-362-3002 (V/TTY) Hmong Yog xav tau kev pab txhais cov ntaub ntawv no kom koj totaub, hu rau 1-800-362-3002 (V/TTY) Laotian grnjv-j;p.odkocx s] ng0Qk.9goNvsk.ooUF dti5ok3mitla [sk 1-800-362-3002 (V/TTY)
NORTHERN WISCONSIN CENTER 2820 E. PARK AVENUE CHIPPEWA FALLS, WI 54729 PHONE: (715) 723-5542 MENDOTA MENTAL HEALTH INSTITUTE CENTRAL WISCONSIN CENTER 317 KNUTSON DRIVE 301 TROY DRIVE MADISON, WI 53704 MADISON, WI 53704 PHONE: (608) 301-9200 PHONE: (608) 301-1000 SOUTHERN WISCONSIN CENTER SAND RIDGE SECURE TREATMENT CENTER 1111 NORTH ROAD 21425 SPRING STREET MAUSTON, WI 53948 UNION GROVE, WI 53182-9708 PHONE: (608) 847-4438 PHONE: (262) 878-2411 WISCONSIN RESOURCE CENTER WINNEBAGO MENTAL HEALTH INSTITUTE P.O. BOX 9 P.O. BOX 16 WINNEBAGO, WI 54985-0009 WINNEBAGO, WI 54985-0016 PHONE: (920) 235-4910 PHONE: (920) 426-4310
DHS/DES F-26003 (07/2008)
1 of 6
YOUR PERSONAL HEALTH INFORMATION RIGHTS
YOU HAVE THE RIGHT TO: SEE OR COPY YOUR PERSONAL HEALTH INFORMATION You have the right to see or copy treatment, payment, and other records used to make decisions about you in the course of providing care, services, or other benefits. Your request must be in writing and should be submitted to the facility where you received treatment or services. We may charge you a fee for costs associated with your request. We are not required to allow you to see or copy psychotherapy notes, or information prepared for use in legal actions or proceedings. Please contact the facility where you received treatment or services for additional information. CORRECT INFORMATION YOU BELIEVE TO BE INCORRECT OR INCOMPLETE - If you believe that your medical information is incorrect or incomplete, you may submit a request to us asking that your information be changed. Your request must be in writing and must include the reason(s) why you believe a change should be made. We are not required to approve your request. We will notify you if we approve your request, or explain the reason(s) for our decision if we deny your request. REQUEST A LISTING OF WHO WAS GIVEN YOUR INFORMATION AND WHY - Upon your request, we will provide you with a list that includes the date we released medical information, the name of the person or organization, a brief description, and the reason for the disclosure. The list will not include releases of information used for treatment, payment, health care operations, or disclosures that were included on listings previously supplied to you. The list will also not include disclosures made for purposes of national security, to correctional institutions, to law enforcement officials while you are in their custody, for certain health care oversight activities, authorized by you in writing, made prior to April 14, 2003, or, made more than 6 years prior to the date of your request. We will provide one list free of charge per year. Contact the facility you received service or treatment from for assistance. REQUEST RESTRICTION(S) ON HOW WE USE OR SHARE YOUR PERSONAL HEALTH INFORMATION You have the right to request a restriction or limitation on how we use or release your medical information for purposes of treatment, payment or operations. We ask that you complete a request form from the treatment location site's Privacy Officer and/or designee and submit it for evaluation. We are not required to agree to your request, and will contact you if we deny your request. REQUEST CONFIDENTIAL COMMUNICATION(S) -You may ask that we communicate with you about health matters in a certain way or at a certain location. For example, if you are an outpatient client, you could request that we contact you at your workplace or via email. We will attempt to accommodate all reasonable requests. To request an alternative method of communication, you must specify how or where you wish to be contacted. REQUEST A PAPER COPY OF THIS NOTICE -You have the right to request a paper copy of this Notice from us at any time. Please contact the facility you received services or treatment from to request a paper copy. You may also view and download a copy of this Notice from our web site. The address is: http://www.dhfs.state.wi.us/
DHS/DES F-26003 (07/2008)
2 of 6
HOW YOUR PERSONAL HEALTH CARE INFORMATION MAY BE USED WITHOUT YOUR WRITTEN PERMISSION
Your medical information may be used and released by us for purposes of treatment, payment for services, administrative and operational purposes, and to evaluate the quality of the services that you receive. Because we provide a wide range and variety of health care and social services to the people in Wisconsin, not all types of uses and releases can be described in this document. We have listed some common examples of permitted uses and releases below. FOR TREATMENT - We may share your medical information when we coordinate services you may need, such as clinical examinations, therapy, nutritional services, medications, hospitalization or follow-up care. For example, your medical information may be given to a pharmacist when you need a prescription filled. FOR PAYMENT We may release your medical information for billing purposes or to collect payment for service and treatment that you receive. For example, your medical information may be shared with your health plan to provide billing information for clinical exams that you have received. We may also share your medical information with government programs such as Workers' Compensation, Medicaid, Medicare, or the Indian Health Services to coordinate benefits and payment. FOR HEALTH CARE OPERATIONS - We may use and release your medical information to ensure that the services and benefits provided to you are appropriate and high quality. For example, we may use your medical information to evaluate our treatment and service programs or to evaluate the services of other providers that use government funds to provide health care services to you. We may combine medical information about many individuals to research health trends, to determine what services and programs should be offered, or whether new treatments or services are useful. TO OTHER GOVERNMENT AGENCIES PROVIDING BENEFITS OR SERVICES - We may release your medical information to government agencies or programs that provide similar services or benefits to you if the release is necessary to coordinate the delivery of your services or benefits, or improves our ability to administer or manage the program. TO KEEP YOU INFORMED We may contact you about reminders for treatment, medical care or health check-ups. We may also contact you to tell you about health related benefits or services that may be of interest to you, and give you information about your care and treatment options. FOR PUBLIC HEALTH - We may release your medical information to local, state or federal public health agencies, subject to the provisions of applicable state and federal law, for the following types of activities: · · · To prevent or control disease, injury or disability or to keep vital statistics records such as data about births and deaths; To notify social service agencies that are authorized by law to receive reports of abuse, neglect or domestic violence, and; To report reactions to medications or problems with products to the Federal Food and Drug Administration.
DHS/DES F-26003 (07/2008)
3 of 6
FOR HEALTH OVERSIGHT We may share your medical information with other divisions of the Department of Health Services and with other agencies for oversight activities as required by law. Examples of these oversight activities include audits, inspections, investigations, and licensing activities. LAW ENFORCEMENT Your medical information may be disclosed to fulfill a requirement by law or law enforcement agencies. For example, medical information may be used to identify or locate a missing person. COURT OR OTHER HEARINGS Your medical information may be disclosed to comply with a court order. FOR RESEARCH We may release your medical information for research projects that have been reviewed and approved by an institutional review board or privacy board to ensure the continued privacy and protection of the medical information. FOR LAWSUITS AND DISPUTES If you are involved in a lawsuit or dispute, we may release your medical information about you in response to a legal order. We may also release your medical information in response to a subpoena, discovery request, or other lawful process by another party involved in the dispute, but only if they have made an effort to tell you about the request or to obtain an order protecting the medical information requested. TO CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS We may release your medical information to a coroner, medical examiner or funeral director, as necessary to carry out their duties as authorized by law. For example, release of medical information may be necessary to identify a deceased person. FOR ORGAN DONATIONS - If you are an organ donor, we may release your medical information to an organization that procures, banks or transports organs for the purpose of an organ, eye, or tissue donation and transplantation. TO AVERT A SERIOUS THREAT TO HEALTH OR PUBLIC SAFETY We may release your medical information if it is necessary to prevent or lessen a serious threat to your health and safety, the health and safety of another person, or to the general public. FOR NATIONAL SECURITY AND PROTECTION OF THE PRESIDENT - We may release your medical information to an authorized federal official or other authorized person for the purpose of national security, providing protection to the President, or to conduct special investigations as authorized by law. TO CORRECTIONAL INSTITUTIONS - If you are an inmate of a correctional institution or in the custody of a law enforcement officer, we may release your medical information to the correctional institution or law enforcement officer, provided the release is necessary to provide you with health care, protect your health and safety, the health and safety of others, or for the safety and security of the correctional institution.
DHS/DES F-26003 (07/2008)
4 of 6
SPECIALIZED GOVERNMENT FUNCTIONS We may release your medical information to the government for specialized government functions. For example, your medical information may be disclosed to the Department of Veterans Affairs to determine eligibility for benefits. If you do not object and the situation is not an emergency and disclosure is not otherwise prohibited by other laws, we are permitted to release your information under the following circumstances: · · · To Individuals Involved In Your Care We may release your medical information to a family member, other relative, friend or other person whom you have identified to be involved in your health care or the payment of your health care; To Family - We may use your medical information to notify a family member, a personal representative or a person responsible for your care, of your location, general condition or death, and; To Disaster Relief Agencies - We may release your medical information to an agency authorized by law to assist in disaster relief activities.
REQUIRED BY LAW In addition to the ways listed previously, your medical information may be disclosed when required by law.
We are required by State and Federal law to maintain the privacy of your medical information. Release of your medical information for reasons other than those necessary for treatment, payment or operations, as outlined in this Notice, or as otherwise permitted by state or federal law, will be made only with your written authorization. You may, revoke, in writing, your authorization at any time. If you revoke your authorization, we will no longer release your medical information to the prior authorized recipient(s), except to the extent that we previously relied on your original authorization to release your information. We are required to abide by the provisions of this Notice. We, however, reserve the right to revise this Notice. We also reserve the right to make the revised Notice effective for the medical information we already have about you, as well as any medical information we create or receive in the future. We will post a current copy of this Notice at our treatment sites and on our website. In addition, you may ask for a copy of our current privacy practices whenever you visit one of our facilities for treatment or to receive health care services.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
You will not lose benefits, eligibility or otherwise be retaliated against for filing a complaint. Please send your written complaints about this Notice, how we handle your medical information, or if you believe your privacy rights have been violated to the Privacy Officer of the facility where you believe the violation occurred. To obtain a complaint form, please contact the facility where you received care or services. The address and phone number of each facility is listed at the beginning of this Notice. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to the Privacy Officer, Department of Health and Human Services, Region V. Office of Civil Rights, 233 North Michigan Avenue, Suite 240, Chicago, Ill 60611. For additional information, call (312) 886-2359, Fax (312) 886-1807, TDD (312) 353-5693.
DHS/DES F-26003 (07/2008) 5 of 6
DEPARTMENT OF HEALTH SERVICES
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
You May Refuse to Sign This Acknowledgement
Client Name (Last, First, MI) Facility Name
I acknowledge I have received a copy of this facility's Notice of Privacy Practices.
For Health Information Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify):
Name Staff Person Making Attempt SIGNATURE Staff Person Making Attempt
Date Attempt Made Date Signed
DHS/DES F-26003 (07/2008)
6 of 6