Wisconsin Community Mental Health Counseling Centers, Inc.

The following categories describe different ways that we use and disclose medical information. For each category of uses and disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses technicians, medical students, or other medical personnel who are involved in taking care of you at the medical center. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we car. arrange for appropriate meals. Different departments of the medical center also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We also may disclose medical information about you to people outside the medical center who may be involved in your medical care after you leave the medical, such as family members, clergy or others we use to provide services that are part of your care.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the medical center may be billed to and payment may be collected from you, an insurance company or third party. For example, we may need to give your health plan information about surgery you received at the medical so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose medical information about you for medical operations. These uses and disclosures are necessary to run the medical center and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many medical center patients to decide what additional services the medical center should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other medical center personnel for review and learning purposes. We may also combine the medical information we have with medical information from other medicals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the medical center.

Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Fund Raising Activities. We may use medical information about you to contact you in an effort to raise money for the medical center and its operations. We may disclose medical information to the Our Medical Center Foundation so that the foundation may contact you in raising money for the medical center. We only would release contact information, such as your name, address, and phone number and the dates you received treatment or services at the medical center. If you so not want the medical center to contact you for funding raising efforts, you must notify the Administrator in writing.

Medical Directory. We may include certain limited information about you in the medical directory while you are a patient at the medical center. This information may include your name, location in the medical center, your general condition (for example, fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest, minister, or rabbi, even if they don't ask for you by name. This is so your family, friends and clergy can visit you in the medical and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the medical. In addition, we may disclose medical information about you to an entity assisting in disaster relief effort so that your family can be notified about your condition, status and location.

Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the medical center. We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at the medical center.

As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law.

To Avert A Serious Threat to Health or Safety. We may use or disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate military authority.

Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
• To prevent or control disease, injury, or disability;
• To report births and deaths;
• To report child abuse or neglect;
• To report reactions to medications or problems with products;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons, or similar process; To identify or locate a suspect, fugitive, material witness, or missing person; About the victim of a crime if, under limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the medical center;
• In emergency circumstances to report a crime, the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the medical facility to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. The release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institutional.

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Health Information Manager. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If your are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the medical center will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the medical center.
To request an amendment, your request must be in writing and submitted to the Health Information Manager. In addition, you must provide a reason that supports your request.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Health Information Manager. Your request must state a time period which may not be longer than six years and may not include dates before January 1, 2002. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Health Information Manager. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example disclosures to your spouse.
To request confidential communication, you must make your request in writing to the Health Information Manager or the Business Officer Manager, if related to payment or billing information. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice ask, your nurse or case manager, or contact the Risk Manager or Compliance Officer at (262) 242-3810.

We reserve the right to change this notice. We reserve the right to make revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the medical center. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you registered at or are admitted to the medical for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

If you believe your privacy rights have been violated, you may file a complaint with the medical center or with the Secretary of the Department of Health and Human Services. To file a complaint with Wisconsin Community Mental Health Counseling Centers, Inc., contact the Compliance Officer at (262) 242-3810 or the Risk Manager at (262) 242-3810. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided you.

This Notice describes Wisconsin Community Mental Health Counseling Centers, Inc. practices. This Notice also covers the practice of:
• Members of Wisconsin Community Mental Health Counseling Centers, Inc. staff and other health care providers granted privileges to provide patient at Wisconsin Community Mental Health Counseling Centers, Inc..
• All employees, staff and other Wisconsin Community Mental Health Counseling Center’s personnel.
• Health care professional authorized to enter information into or consult your medical record.
• All departments of Wisconsin Community Mental Health Counseling Centers, Inc..

All these entities, sites and locations follow the terms of this Notice. In addition, these entities, sites and locations may share health information with each other for treatment, payment or operations purposes described in this Notice.