THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice applies to all protected health information (“PHI”) maintained by the current or future covered entity affiliates of Pain Physicians of Wisconsin, S.C., and their affiliated Ambulatory Surgery Centers which include Waukesha Surgicenter, LLC, and Milwaukee Surgicenter, LLC. For purposes of this Notice, the affiliates of Pain Physicians of Wisconsin will be referred to as Pain Physicians of Wisconsin and their affiliated surgery centers.
This Notice describes how members of the Pain Physicians of Wisconsin SC respective workforces, including employees, medical staff members, students, and volunteers, will use and disclose PHI Pain Physicians of Wisconsin and their surgery centers. If you have any questions after reading this Notice, please contact Pain Physicians of Wisconsin’s Privacy Officer. This Notice does not apply to Pain Physicians of Wisconsin and their affiliated surgery centers as employers.
Protected Health Information (“PHI”) is any individually identifiable information, whether oral or recorded in any form or medium, that is created or received by a health care provider, health plan, or health care clearinghouse, and that relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual, and that either identifies an individual (for example, an individual’s name, social security number, or medical record number) or can reasonably be used to identify the individual (for example, your address, telephone number, or birth date).
We are committed to the privacy of your PHI, and we comply with applicable law and accreditation standards regarding patient privacy. PHI about you is personal. PHI may be in paper or electronic records but could also include photographs, videos and other electronic transmissions or recordings that are created during your care and treatment. A record of the care and services you receive is needed to provide you with quality care and to comply with legal requirements.
The law requires us to:
Pain Physicians of Wisconsin and their affiliated surgery centers may use or disclose your PHI for treatment purposes or for other purposes permitted or required by applicable laws, rules, or regulations. Except when using or disclosing your PHI for treatment purposes or when using or disclosing your PHI as required by applicable laws, rules, or regulations, Pain Physicians of Wisconsin and their surgery centers will follow a “Minimum Necessary” standard and will make reasonable efforts to limit the use and disclosure of your PHI to accomplish the intended purpose.
Uses and disclosures of PHI not covered by this Notice or the laws that apply to Pain Physicians of Wisconsin and their affiliated surgery centers will be made only with your permission.
In Certain Circumstances We May Use and Disclose PHI About You Without Your Written Permission.
Right to Request Restrictions: You have the right to request certain restrictions of our use or disclosure of PHI for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care or the payment for your care. We are not required to agree to your request in most cases. If we agree to the restriction, we will comply with your request unless the PHI is needed to provide you emergency treatment. We must, however, agree to your request to restrict our disclosure of your PHI to your health plan when you have paid us out-of-pocket in full for the health care item or service, we provided you. A request for restriction should be made in writing. To request a restriction, please contact the Medical Records Department.
Right to Inspect and Copy: You have the right to inspect and receive a copy of PHI about you that may be used to make decisions about your health. A request to inspect your records may be made to the Medical Records Department. For copies of your PHI, requests must go to the Medical Records Department. There may be a charge for these copies. For copies of billing records, you may contact the Billing Department.
Right to Amend: If you feel that PHI, we have about you is incorrect or incomplete, you may ask us to amend the PHI, for as long as Pain Physicians of Wisconsin and their affiliated surgery centers maintain the PHI. Requests for amending your PHI should be made to the Medical Records Department. Pain Physicians of Wisconsin and their affiliated surgery centers will respond to your request within 60 days after you submit the written amendment request form. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the PHI you wanted amended. If we accept your request to amend the PHI, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that PHI.
Right to a List of Disclosures: You have the right to request a list of instances in which we or our business associates disclosed your PHI for purposes other than treatment, payment, health care operations, disclosures authorized by you or made to you, and certain other activities. A request for this list of disclosures should be made in writing to the Medical Records Department. The first list you request from Pain Physicians of Wisconsin and their affiliated surgery centers 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 Alternate Means of Communication: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location. We will accommodate all reasonable requests. You must make any such request in writing submitted to the Privacy Officer.
Right to Revoke Permission: If you authorize Pain Physicians of Wisconsin and their affiliated surgery centers to use or disclose your PHI, you may revoke that permission, in writing, at any time. We are unable to take back any disclosures we have already made with your permission. To revoke a permission, please contact the Medical Records Department.
Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with Pain Physicians of Wisconsin and their surgery centers or with the Secretary of the Department of Health and Human Services. To file a complaint with Pain Physicians of Wisconsin and their surgery centers you must put your complaint in writing and address it to the Privacy Officer for PPW. Filing a complaint will not affect your care and treatment.
Right to Appoint a Personal Representative: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI.
Important Notice: We reserve the right to revise or change this Notice and to make the new Notice provisions effective for all PHI that Pain Physicians of Wisconsin and their affiliated surgery centers maintain. Each time you register for health care services at a site covered by this Notice, the most current copy of this Notice will be available for you. You have a right to obtain a paper copy of this Notice upon request.
Copyright © 2022 Pain Physicians of Wisconsin. All Rights Reserved.