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Privacy Notice for
Wisconsin Well Woman Program
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
Understanding Your Health Record/Information
Each time you visit a hospital, physician, nursing home or
other healthcare provider, a
record of your visit is made. Typically, this record
contains your symptoms, examination and test results, diagnoses, treatment and a
plan for ongoing and future care or treatment. This information, often referred
to as your health or medical record, serves as a:
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Basis for planning your care and treatment
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Means of communication among the health professionals
who contribute to your care
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Legal document describing the care you received
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Means by which you or a third-party (insurance company)
can verify that services billed were actually provided
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A tool in educating health professionals
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A source of data for facility planning and marketing
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A tool with which we can assess and continually work to
improve the services we provide
Your Health Information Rights
Although your health record is the physical property of the
La Crosse County Health Department, the information belongs to you. You have
the right to:
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Request Restrictions. You have the right to
request restrictions on certain uses and disclosures of your health
information. WWWP is not required to agree to the restrictions that you
request. If you would like to make a request for restrictions, you must
submit your request in writing to the Privacy Officer of the La Crosse County
Health Department. We are not required to agree with your request.
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Obtain a Paper Copy. You have a right to receive
a paper copy of this Notice of Privacy Practices at any time. Copies of this
Notice may be obtained at the Health Department and are also posted at our
website at
www.co.la-crosse.wi.us/health
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Inspect and Obtain Copies. You have the right to
inspect and copy health information about you that may be used to make
decisions about your plan benefits. An Authorization for Disclosure of
Confidential Information form will be completed when submitting your
request. We may charge you a reasonable fee to cover expenses associated with
your request.
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Request to Correct Health Information You Believe to
be Incorrect or Incomplete. You have a right to request that WWWP amend
your health information that you believe is incorrect or incomplete. We are
not required to change your health information and if your request is denied,
we will provide you with information about our denial and how you can disagree
with the denial. An amendment is available for you to use and submit to the
Privacy Officer of the Health Department.
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Obtain an Accounting of Disclosures of your Health
Information. You have the right to receive a list of disclosures made for
any other reason than for purposes of payment functions, health care
operations or made to you. To request this accounting of disclosures, you
must submit your request in writing to the Privacy Officer of the Health
Department. Request for Accounting form is available to may this request.
Your request should specify a time period of up to six years and may not
includes dates before April 14, 2003. WWWP will provide one list per 12 month
period free of charge; we may charge you for additional lists.
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Request That You Be Informed About Your Health in a
Way or at a Location That Will Keep Your Information Private: You have
the right to receive your health information, appointment reminders, followup,
etc. through a reasonable alternative means or at an alternative location. To
request alternative communications, submit your request using the Confidential Alternate Communication Request
form to the Privacy Officer
of the Health Department. Your request will be evaluated and we will let you
know if it can be done.
La Crosse County Health Department Responsibilities
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Maintain the privacy of your health information
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Provide you with a notice as to our legal duties and
privacy practices with respect to information we collect and maintain about
you
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Abide by the terms of this notice
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Notify you if we are unable to agree to a requested
restriction
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Accommodate reasonable request you may have to
communicate health information by alternative means or at alternative
locations
We reserve the right to change the terms of this Notice and
to make new provisions effective for all protected health information we
maintain. Revised Privacy Notices will be posted at our website at
http://www.co.la-crosse.wi.us/health. Copies will also be available at
the La Crosse County Health Department.
For More Information or to Report a Problem
If you have questions and would like additional
information, you may contact the Privacy Officer for the Health Department at
608-785-9723
If you believe your privacy rights have been violated, you
can file a complaint with the Privacy Officer for the Health Department or with
the State Secretary of Health and Human Services. There will be no retaliation
for filing a complaint.
How Wisconsin Well Woman Program May Use or Disclose
Your Health Information
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Treatment: We may use your health information to
provide, coordinate or manage your health care. We will share your health
information with others from your healthcare team including but not limited
to, physicians, lab, hospital and emergency providers, rehabilitation therapy,
pharmacy and others that may be involved in the delivery of care to you.
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Payment Functions: We may use or disclose health
information about you to determine eligibility for plan benefits, obtain
premiums, facilitate payment for the treatment and services you receive from
health care providers, determine plan responsibility for benefits, and to
coordinate benefits. For example, payment functions may include reviewing the
medical necessity of health care services, determining whether a particular
treatment is experimental or investigational or determining whether a
treatment is covered under your plan.
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Carry out Healthcare Operations: We may use and
disclose health information about you to carry out necessary insurance-related
activities. For example, such activities may include conducting quality
assessment and improvement activities; submitting claims for stop-loss
coverage; conducting or arranging for medical review, legal services, audit
services, business planning, management and general administration.
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Other Circumstances of Use or Disclosure
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Information required by Wisconsin State or Federal law
or valid subpoena
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Disclosure to public health authorities for purposes
related to preventing or controlling disease, injury or disability; reporting
child abuse or neglect; reporting domestic violence; reporting to the Food and
Drug administration problems with products and reactions to medications; and
reporting disease or infection expose
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Disclosure to health agencies during the course of
audits, investigations, inspections, licensure and other proceedings related
to oversight of the health care system
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To coroners, medical examiners and funeral directors to
assist in identification or determination of cause of death
Required Authorization for
Disclosure
Except as described in this Notice
of Privacy Practices, we will not use or disclose your health information
without written authorization from you. If you do authorize us to use or
disclose your health information for another purpose, you may revoke your
authorization in writing at any time. If you revoke your authorization, we will
no longer be able to use or disclose health information about you for the
reasons covered by your written authorization, though we will be unable to take
back any disclosures we have already made with your permission.
Effective Date of Notice: April 14, 2003
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