11725 N Port Washington Rd #250 Mequon, WI 53092
W189 N11100 Kleinmann Dr #105 Germantown, WI 53022

Mequon Vascular Associates, S.C.
Notice of Privacy Practices
Effective Date: December 13, 2016

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand that information about you and your health is personal. We are committed to protecting your health information. We are required by applicable federal and state law to maintain the privacy of your health information. We are also required by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information as set forth below. We will restrict our uses or disclosures of your health information in accordance with the more stringent standard. We must follow the privacy practices described in this Notice while it is in effect.

We may change our privacy practices and the terms of this Notice at any time, if such changes are permitted by law. If we change the terms of this Notice, those changes will apply to all health information that we already hold, as well as to new information we create or receive after the changes. Before we make significant changes in our privacy practices, we will change this Notice and post it in our office. You may request a copy of our current Notice at any time.

How We May Use and Disclose Your Health Information

We have described below the different ways we use and disclose health information:

Treatment: We may use and disclose your health information to provide, coordinate, or manage your health care and any related services. For example, we may disclose your health information to a pharmacy to fill a prescription. We may also disclose your health information to other physicians who may be treating you or who have consulted us about your medical care.

Payment: Your health information will be used, as needed, to obtain payment for the medical treatment and services that we provide to you. For example, we may disclose your health information to your health insurance company to determine whether or not you are eligible for benefits or whether a particular service is covered under your health plan. In certain situations, we may disclose your health information to a collection agency if a bill is not paid. We may also disclose your health information to another health care provider for their payment related activities.

Health Care Operations: We may use or disclose your health information for our own health care operations to run our practice and to help us provide quality care to all of our patients. For example, we may use your health information to review our treatment and services and to evaluate the performance of our staff in caring for you.

Business Associates: We are permitted by law to use other persons or entities as “Business Associates” to carry out treatment, payment or health care operations that may involve the use and disclosure of your health information. For example, we may use a billing service or accounting service to handle some billing and payment functions or may consult with our legal counsel on matters affecting our practice.

Appointment Reminders, Treatment Alternatives, and Health-Related Benefits: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care:  We may disclose health information about you to a family member or friend who is involved in your medical care or who is involved in paying for your medical care.  We may also disclose your location, condition, or death in efforts to locate or notify family members or friends involved in your care. We will use our professional judgment and disclose only information that is directly relevant to the person’s involvement in your health care or payment for your health care.  As further discussed below, you may object to these disclosures by contacting our Clinic Manager

Other Uses and Disclosures

Federal privacy rules allow us to use or disclose your health information without your permission or authorization for a number of other reasons, including the following:

When Legally Required: We may disclose your health information when we are required to do so by federal, state or local law.

For Public Health Activities: We may disclose your health information for public activities and purposes such as:

  • To prevent, control, or report disease, injury, or disability as permitted by law;
  • To report vital events such as birth or death as permitted or required by law;
  • To conduct public health surveillance, investigations, and interventions as permitted or required by law;
  • To collect or report adverse events and product defects, track FDA-regulated products, enable  product recalls, repairs or replacements to the FDA, and to conduct post-marketing surveillance;
  • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease, as authorized by law; or
  • To report to an employer information about an individual who is a member of the workforce as legally permitted or required.

Disaster Relief Efforts: We may disclose your health information to organizations for the purpose of disaster relief efforts.

To Report Suspected Abuse, Neglect, or Domestic Violence: We may notify government authorities if we believe that a patient is the victim of abuse, neglect, or domestic violence.

To Conduct Health Care Oversight Activities: We may disclose your health information to authorities or agencies for oversight activities allowed by law including audits; civil, administrative or criminal investigations, legal proceedings, or actions; inspections; licensure or disciplinary actions.

Legal Proceedings, Lawsuits, and Other Legal Actions: We may disclose your health information to courts, attorneys and court employees when we receive a court order, subpoena, discovery request, warrant, summons, or other lawful instructions from those courts or public bodies and in the course of certain other lawful, judicial or administrative proceedings, or to defend ourselves against a lawsuit brought against us.

For Law Enforcement Purposes: We may disclose your health information to a law enforcement official for law enforcement purposes such as:

  • For reporting certain types of wounds or other physical injuries;
  • Pursuant to court order, court-ordered warrant, subpoena, summons, or similar process;
  • For the purpose of identifying or locating a suspect, fugitive, material witness, or missing person;
  • Under certain limited circumstances, when you are the victim of a crime;
  • To a law enforcement official if we suspect that your health condition was the result of criminal conduct; or
  • In an emergency to report a crime.

To Coroners and Funeral Directors: We may disclose your health information to a coroner or medical  examiner for identification purposes, to determine cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his duties. We may disclose such information in reasonable anticipation of death.

Organ Donation: We may disclose your health information for cadaveric organ, eye, or tissue donation purposes.

For Research Purposes: We may use or disclose your health information for research when the use  or disclosure for research has been approved by an  institutional review board that has reviewed the  research proposal and research protocols to address the privacy of your health information.

In the Event of a Serious Threat to Health or Safety:  We may, consistent with applicable law and ethical  standards of conduct, use or disclose your health  information if we believe, in good faith, that such  use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety  of the public.

For Specified Government Functions:  In certain  circumstances federal regulations authorize us to use or disclose your health information to facilitate specified government functions relating to military and veterans activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.

For Worker’s Compensation: We may release your health information to comply with worker’s compensation laws or similar programs.

Disclosures Requiring Your Permission

In other situations not covered by this Notice, we will not disclose your health information other than with your written authorization. An example would be the following:

Marketing: We would obtain your permission before using or disclosing your health information for marketing purposes.

Withdrawing Your Permission

If you choose to authorize a use or disclosure, you may later revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

Other Restrictions

State and federal law may have more requirements than HIPAA on how we use and disclose your health information. If there are specific, more restrictive requirements, even for some of the purposes listed above, we may not disclose your health information without your written permission as required by such laws. We may also be required by law to obtain your written permission to use and disclose your information related to treatment for a mental illness, developmental disability, or alcohol or drug abuse.

There may be other restrictions on how we use and disclose your health information than those listed above.

Patient’s Rights

We have described below the rights you have with respect to your health information. In most cases, we require that you exercise those rights by making written requests to our Clinic Manager whose contact information is listed on the last page of this Notice. In addition, our office staff will assist you in making your written request on forms we will provide and in making sure that the Clinic Manager receives your request.

  • The right to inspect and copy your health In most cases, you may look at or get a copy of your health information that our staff uses for making decisions about your medical care. To look at or get a copy of your health information, you must submit a written request to our Clinic Manager. If you request a copy of your information, we may charge you a fee for the cost of copying, mailing, or other costs incurred by us in complying with your request. You have the right to request, in writing, that we transmit a copy of your health information directly to another individual.

To obtain your health information or billing information, contact our Clinic Manager listed on the last page of this Notice.

If we deny your request to look at or copy your health information, we will explain why we denied your request. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

  • The right to request a restriction on uses and disclosures of your health information. You may ask not to use or disclose certain parts of your health information for the purposes of treatment, payment, or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care. Your request must be made in writing to our Clinic Manager and state the specific restriction requested and to whom you want the restrictions to apply.

We are not required by law to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If we agree to the requested restriction, we may not use or disclose your health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction.

  • The right to request to receive confidential

communications from us by alternative means or at an alternative location. You may have the right to request that we communicate with you in a

confidential manner, such as sending mail to an  address other than your home. Your request must be made in writing to our Clinic Manager and state the specific manner or location for us to use to communicate with you. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or for an alternative address or other method of contact. We will not require you to provide an explanation for your request.

  • The right to request amendments to your health

information. You may request an amendment of your health information for as long as we maintain this information. Your request must be made in writing to our Clinic Manager and state a reason to support the requested amendments. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us  and we may prepare, and provide you a copy of,  a rebuttal to your statement.

  • The right to receive an accounting. You have the right to request an accounting of certain disclosures for your health information for purposes other than treatment, payment, or health care operations as described in this Notice. We are also not required to account for disclosures that you agreed to by signing an authorization form, disclosures to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Clinic Manager and specify the time period sought for the accounting. We are not required to provide an accounting for

the disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-base fee.

  • The right to receive notification of a breach: The privacy and security of your health information we take seriously and have policies and safeguards in place to protect against unauthorized access, use or disclosure. Following any breach of unsecured health information, we will notify any affected individuals as required by law.
  • The right to obtain a paper copy of this Notice. Upon request, we will provide a separate paper copy of this Notice even if you have already received a copy of this Notice or have agreed to accept this Notice electronically.

File a complaint: You have the right to file a complaint with us if you believe your privacy rights have been violated. To file a complaint, call our President at (262) 240-9640. You also have the right to complain to the United States Secretary of the  Department of Health and Human Services. We will not take any action against you for filing a complaint.

To exercise any of the above rights, please submit your written requests directly to our Clinic Manager at the following address:

Mequon Vascular Associates, S.C.
11725 N. Port Washington Rd., Suite 250
Mequon, WI 53092
Attn: Clinic Manager
Phone: (262) 240-9640 Fax: (262) 240-9657

If you have any questions or need further assistance regarding this Notice, you may contact the Clinic Manager at the address or telephone number listed above.

This notice is effective on and after December 13, 2016, unless and until it is revised by Mequon Vascular Associates, S.C.