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
Your Health Care Information - Protecting Your Privacy
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.
Menominee Tribal Clinic's Responsibilities
It is your right as a patient to be informed of Menominee Tribal Clinic's legal duties with respect to protection of the privacy of your personal health information.
Menominee Tribal Clinic is required to:
• Maintain the privacy of your protected health information;
• Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; and
• Abide by the terms of this notice.
Menominee Tribal Clinic reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains.
Menominee Tribal Clinic will promptly revise and distribute its notice whenever there is a substantial change to any of its privacy practices.
Menominee Tribal Clinic will not use or disclose your protected health information without your authorization, except as described in this notice.
Your Health Information Rights
You have the right to:
• Request a restriction on certain uses and disclosures of your protected health information.
You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or Menominee Tribal Clinic's payment or health care operation activities. However, Menominee Tribal Clinic is not required to agree to your requested restriction.
• Receive Confidential Communications.
You have the right to request that Menominee Tribal Clinic communicate your protected health information to you by alternative means or at alternative locations. Menominee Tribal Clinic shall accommodate reasonable requests.
• Inspect and obtain a copy of your health record.
You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be in submitted in writing to the Medical Records Department. This right may not apply to certain types of psychotherapy notes and Menominee Tribal Clinic may charge you a reasonable fee for a copy of your health care record.
• Amend your health record.
You have the right to request an amendment to your health care record if you believe your protected health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health record should be changed. If Menominee Tribal Clinic did not create the health information you believe is incorrect or if Menominee Tribal Clinic disagrees with you, Menominee Tribal Clinic may deny your request.
• Obtain an accounting of disclosures of your protected health information.
You have the right to an accounting of disclosures of your protected health information that Menominee Tribal Clinic has made in compliance with state and federal law. This accounting period begins as of April 14, 2003 ; no releases will be made prior to April 14, 2003 . The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. If you request the accounting more than once in a 12-month period, Menominee Tribal Clinic may charge you a reasonable fee for each subsequent request.
• Obtain a paper copy of the notice upon request.
You have the right to obtain a paper copy of this notice upon request.
Uses and Disclosures for Treatment, Payment and Health Care Operations
Menominee Tribal Clinic is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.
Menominee Tribal Clinic may use or disclose your health information for treatment.
Menominee Tribal Clinic may use or disclose your protected health information in the provision, coordination or management of your health care.
Example: Your protected health information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
Example: Menominee Tribal Clinic may use your protected health information to provide you with an appointment reminder. However, if you specifically request that we not contact you with appointment reminders, we will honor that request and remove you from our call system.
Example: Menominee Tribal Clinic will use a sign in sheet at the Pharmacy where you will be asked to sign your name when picking up medication. The Pharmacist will explain your medication at the pick up window.
Example: Menominee Tribal Clinic will call you by name in the waiting room areas when your Health Care Provider is ready to see you.
Example: Menominee Tribal Clinic may send you information about treatment alternatives or other health related services that may be of interest to you.
Menominee Tribal Clinic may use or disclose your protected health information for payment.
Menominee Tribal Clinic may use or disclose your protected health information to obtain reimbursement for the provision of health care services. A bill may be sent to you directly or a third party payer. The bill may include information that identifies you, your procedures and diagnosis, supplies used, and your treatment.
Example: Menominee Tribal Clinic may use or disclose your information to your insurer to obtain payment for the provision of health care services. This may include activities that your health insurance plan may undertake before it approves or pays for your care, including but not limited to, making a determination of eligibility or coverage of insurance benefits, reviewing services provided to you for “medical necessity”, and undertaking utilization review activities.
Menominee Tribal Clinic may use or disclose your health information for routine health care operations.
Menominee Tribal Clinic may use or disclose your health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.
Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization
Without your written authorization, Menominee Tribal Clinic may use or disclose your protected health information for the following purposes:
As Required by Law : Menominee Tribal Clinic may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:
• Disclosures about victims of elderly or child abuse;
• Disclosures for judicial and administrative proceedings; or
• Disclosures for law enforcement purposes.
Public health: As required by law, Menominee Tribal Clinic may disclose your protected health information to the State of Wisconsin or applicable Federal Agency for the purpose of statutory reporting. All disclosures made are in accordance with applicable Tribal/State/Federal laws.
Menominee Tribal Clinic may disclose your protected health information to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.
Menominee Tribal Clinic may disclose your protected health information to a tribal/county agency investigating child/elder abuse.
Menominee Tribal Clinic may disclose your protected health information to the Food and Drug Administration (FDA).
Menominee Tribal Clinic may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.
Menominee Tribal Clinic may disclose your protected health information that is reasonably related to a work related illness or injury if an application for workers' compensation has been filed.
Victims of abuse, neglect or domestic violence: Menominee Tribal Clinic may disclose protected health information if Menominee Tribal Clinic reasonably believes that an individual is a victim of child or elderly abuse.
Health oversight activities: Menominee Tribal Clinic may disclose your protected health information without your authorization to a state or federal agency for activities authorized by law. Oversight activities may include investigations, audits, inspections and other actions.
Judicial and Administrative Proceedings: Menominee Tribal Clinic may disclose your protected health information in response to a court order. Menominee Tribal Clinic may disclose your protected health information in response to a subpoena if Menominee Tribal Clinic is a party to a court action. Menominee Tribal Clinic may disclose your protected health information in response to a subpoena from a state or federal agency.
Law enforcement: Menominee Tribal Clinic may disclose your protected health information to tribal/county law enforcement officials for the reporting and investigation of elderly and/or child abuse. Menominee Tribal Clinic may disclose your protected health information to state and federal law enforcement officials, or to a law enforcement official in response to a court order.
For activities related to death: Menominee Tribal Clinic may use or disclose your protected health information to coroners, medical examiners and funeral directors.
For cadaveric organ, eye or tissue donation purposes: Menominee Tribal Clinic may use or disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation or cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation, consistent with applicable laws.
Research: Menominee Tribal Clinic may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.
To avoid a serious threat to health or safety: Menominee Tribal Clinic may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.
Disclosures for specialized government functions: Menominee Tribal Clinic may disclose protected health information for national security, for protection of the President and for medical suitability determination or of Armed Forces personnel to a state or federal agency.
Menominee Tribal Clinic may disclose protected health information to limited staff of a correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.
Workers compensation: Menominee Tribal Clinic may disclose protected health information reasonably related to a workers' compensation injury.
Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your protected health information requires Menominee Tribal Clinic to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to Menominee Tribal Clinic's Medical Records Department.
Patient Complaint Process
If you believe your privacy rights have been violated, you may file a complaint with Menominee Tribal Clinic or with the Secretary of the Department of Health and Human Services. We will provide you with the address to file your complaint with the Secretary of the Department of Health & Human Services upon request.
To file a complaint with Menominee Tribal Clinic please contact the Menominee Tribal Clinic's Compliance Officer who will provide you with the necessary assistance.
Questions or Concerns
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:
Laurie Boivin , Compliance Officer
Menominee Tribal Clinic
P.O. Box 970
Keshena , WI 54135
715-799-5490
laurieb@mtclinic.net
Effective Date: This Notice of Privacy Practice is effective as of April 14, 2003 .