THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW THIS NOTICE CAREFULLY.
This information is available in Spanish and Hmong. Please ask a staff member if you need a copy in either of these languages.
Esta información esta disponible en español. Se usted necesita una copia en español, por favor pregunte a miembro del personal.
Cov ntau ntawv no nws muaj cov pes lus hmoob. Yog tias koj xa tau ib daim ntawv uas pes lus hmoob no thov noog cov neeg ua hauj lwm.
When we refer to "you" or "your" in this Notice we refer to the person or persons receiving the services provided by Children's Hospital of Wisconsin Community Services. When we refer to disclosures of information to "you", we mean disclosures to adults or children, the parent of the children, guardian or other person legally authorized to receive information about the person or persons receiving services from Children's Hospital of Wisconsin Community Services.
Who follows this Notice:
This Notice applies to all protected health information (PHI) maintained by Children's Hospital of Wisconsin Community Services for services provided at any office of Children's Hospital of Wisconsin Community Services or services provided at non-office locations by any employee of Children's Hospital of Wisconsin Community Services in the course of their employment. If you have any questions after reading this Notice, please contact the Children's Hospital of Wisconsin Community Services Privacy Officer.
Each time you receive services from Children's Hospital of Wisconsin Community Services, a record of the services provided is created. Typically this record could contain information about the type of service you have received, the dates of service and the results of the service provided. At times this will include the reason you have come to Children's Hospital of Wisconsin Community Services for service and the agreed upon goals of the service provided.
This Notice applies to all of the records containing PHI created as a result of services provided by Children's Hospital of Wisconsin Community Services.
Our Pledge to Protect Your Health Information: We are required by law to maintain the privacy of your PHI and provide you with a description of our privacy practices. We will abide by the terms of this Notice.
How we may use and share your health information with others
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. For example, a worker or therapist may use PHI about you or your child from a clinic record to determine which treatment option, such as family or individual therapy, best addresses your needs. Your worker or therapist may discuss information found in your record with our consultants, a colleague or their supervisor to assist in treatment planning for you or your child.
For Payment: We may use and disclose PHI to send bills and collect payment from you, your insurance company, or other payors, such as governmental agencies, for the treatment or other related services you receive from Children's Hospital of Wisconsin Community Services, so we can receive payment for the treatment services provided to you. Examples of payment related activities are: making a determination of eligibility or coverage for insurance benefits, processing and sending claims to your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.
For Health Care Operations: We may disclose PHI about you for business operations of Children's Hospital of Wisconsin Community Services. These uses and disclosures are necessary for Children's Service Society to provide quality care and cost-effective services. The operationsuso disclose PHI includes, but is not limited to, quality assessment activities, employee review activities, and licensing activities. For example, we may share your PHI with third parties that perform various business activities (such as billing or typing services). We will require these third parties to have a contract with us that requires them to safeguard the privacy of your PHI. Quality assessment activities may include evaluating the performance of your therapist or examining the effectiveness of treatment provided to you when compared to patients in similar situations.
Future Communications and Fundraising Activities: We may use your name, address and telephone number to contact you to provide newsletters, information about programs or other services we offer or to raise money for health programs. We may disclose this information to Children's Hospital of Wisconsin Foundation so the Foundation may contact you relating to raising money for Children's Hospital of Wisconsin, of which Community Services is an affiliate. If you do not want Children's Hospital's Foundation to contact you relating to fundraising efforts, you must notify us in writing. Please contact the Privacy Officer to assist you with this request.
Appointments: We may use your PHI for the purpose of sending to you appointment reminders through the mail or by telephone. Messages left for you will not contain specific health information.
Required or Permitted by Law: Children's Hospital of Wisconsin Community Services is required by law to disclose your PHI in certain circumstances:
- For public health oversight activities
- To facilitate the functions of federal or state governmental agencies
- To report suspected elder or child abuse to law enforcement agencies responsible to investigate or prosecute abuse
- In response to a valid court order
- To the Department of Health and Family Services, a protection or advocacy agency, or law enforcement authorities investigating abuse, neglect, physical injury, death or violent crimes
- To your court-appointed guardian or an agent appointed by you under a health care power of attorney
- Prison officials if you are in custody
- Worker's Compensation officials if your condition is work-related
- If necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public
When sharing PHI with others outside of Children's Hospital of Wisconsin Community Services, we share only what is reasonably necessary unless we are sharing PHI to help treat you, in response to your written permission, or as the law requires. In these cases, we share all the PHI that you or the law requires.
YOUR HEALTH INFORMATION RIGHTS
You have the following rights regarding your PHI we maintain. To exercise any of the rights discussed in the remainder of this section, please contact the Privacy Officer for Community Services located at Children's Hospital of Wisconsin 9000 W. Wisconsin Avenue, PO Box 1997, MS 940, Milwaukee, WI 53201.
Right to Request Restrictions: You have the right to request certain restrictions of use and disclosure of your PHI by Children's Hospital of Wisconsin Community Services 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. Children's Hospital of Wisconsin Community Services is not required to agree to restrict the use and disclosure of your PHI. A request for restriction must be made in writing using the form available from the Privacy Officer.
Right to Inspect and Copy: With a few exceptions you have the right to inspect and receive a copy of your PHI. Should you wish to review or copy your PHI you should make a request using the form available from the Privacy Officer. We will arrange for your therapist or another health professional in our clinic to review the PHI with you in our office or to copy the information requested. We may charge you a reasonable fee if you want a copy of your PHI.
Right to Amend or Correct Your Record: If you feel the PHI we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is maintained by Children's Hospital of Wisconsin Community Services. Requests for amendment or correction should be made by submitting a form requesting amendment or correction available from the Privacy Officer. We will respond to your request within 60 days after you submit the form. We are not required to agree to the amendment.
Right to an Accounting of Disclosures: You have a right to request an accounting for disclosures. This is a list of those people with whom Children's Hospital of Wisconsin Community Services may have shared your PHI, with the exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. We may charge you a reasonable fee if you request more than one accounting for disclosures in any 12-month period. The request cannot include any disclosures made before April 14, 2003. Requests for an accounting of disclosures should be made by submitting a form requesting an accounting of disclosures to the Privacy Officer. This form is available from the Privacy Officer. We will respond to your request within 60 days after you submit the request.
Right to Request Confidential Communications: You have the right to ask that we communicate your PHI to you in a certain way or a certain location. For example, you can request that we contact you only at work or by mail. We will accommodate reasonable requests.
Right to Revoke Authorization: Uses and disclosures of PHI not covered by this Notice or the laws that apply to Children's Hospital of Wisconsin Community Services will be made only with your authorization. If you authorize Children's Hospital of Wisconsin Community Services to use or disclose your PHI, you may revoke that authorization in writing at any time. We are unable to reverse any disclosures we have made previously with your authorization. To revoke an authorization please contact your therapist or the clinic where you receive services.
Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with Children's Hospital of Wisconsin or with the Secretary of the Department of Health and Human Services. To file a complaint with Children's Hospital of Wisconsin Community Services, contact the Privacy Officer. All complaints must be made in writing. The Privacy Officer will assist you in filing your complaint. Filing a complaint will not affect your care.
We reserve the right to revise or change this Notice. Each time you sign a consent for treatment at a site covered by this Notice we will provide a copy of this Notice in effect at that time.
Effective Date: April 14, 2003
How to Contact Us:
Children's Hospital of Wisconsin Community Services Privacy Officer: 414-266-1773 or 877-659-5200
Secretary of Department of Health and Human Services: 877-696-6775