No Surprise Act
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises
HIPAA 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.
Understanding your Health Records Information
Each time you visit a hospital, physician, or healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information often referred to as your health or medical records, serves as a basis for planning your care and treatment, and your care and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, and better understand who, what, where, and why others may access your information, and make more information decisions when authorizing disclosure to others.
Your Health Information Rights:
Unless otherwise required by law, your record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to request a restriction on certain used and disclosures of your information, and re quest amendments to your health record. This includes the right to obtain a paper copy of the notice of information practices upon request, inspect and obtain a copy of your health record, obtain an accounting of disclosures of your health information, to receive confidential communications of your health information by alternative means or at alternative location, revoke your authorization to use or disclose health information except to the extent that action has already been taken. Requests must be submitted in writing to the Privacy Officer (name and number listed on the last page of this notice). This practice may charge you a fee for the coast of copying, mailing, or other costs incurred by the practice in complying with your request.
This organization is required to maintain the privacy of your information. In addition, provide you with a notice as to our legal duties and privacy practices with respect of information we collect and maintain about you. This organization must abide by the terms of this notice, notify you if we are unable to agree to agree to a requested restriction, and accommodate reasonable requests you may have to communicate health information by alternative means or at alternative location. We reserve the right to change our practices change, we will mail a revised notice to the address you’ve supplied us. If we maintain a website that provides information about our
customer services or benefits we will post our new notice on that website. We will not use or disclose your health information without your authorization, except as described in this notice.
For More Information or To Report a Problem:
If you have questions and would like additional information, you may contact the Privacy Officer. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. You may also provide complaints to the practice verbally or in writing. Such complaints should be directed to the practice’s Privacy Officer. There will be no retaliation for filing a complaint.
Examples of Disclosures for Treatment, Payment, and Health Operations
We will use your health information for treatment. For example: Information obtained by a healthcare practitioner will be recorded and used to determine the course of treatment that should work best for you. By way of example, your physician will document in your record their expectation of the members of your healthcare team. Member of your healthcare team will them record the actions they took and their observation. We will also provide your other practitioners with copies of various reports that should assist them in treating you.
We will use your health information for payment. For example: A bill may be sent to you or third-party payer. The information on or accompanying the bill includes information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will them be used in an effort to continually improve the quality and effectiveness of the healthcare and services we provide.
Business Associates: There may be some services provided in our organization through contacts with Business Associates. Examples include physician services in the emergency department and radiology and laboratory test. When these service are contracted we may disclose some or all of your health information to our Business Associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the Business Associate to properly safe guard your information.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with Family, health professionals, using their best judgment, may disclose to a family member other relatives, close person friends or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Additional uses and disclosure Permitted without Authorization or Opportunity to Object
In addition to treatment, payment and health care operations, the practice may use or disclose your protected information without your permission or authorization in certain circumstances, including:
When legally required: the practice will comply with any Federal, State, or local law that requires it to disclose your protected health information.
When there are risks to Public Health: the practice may disclose your protected health information for public health purposes, including to, as permitted by law:
1. Prevent, control, or report disease, injury, or disability.
2. Report vital events such as birth or death.
3. Conduct public health surveillance, investigations, and interviews.
4. Collect or report adverse events and produce defects, track FDA regulated products,
enable produce recalls, repair, or replacements, and conduct post marketing surveillance. 5. Notify a person who has been exposed to a communicable disease (s) or who may
be at risk of contracting or spreading a disease. 6. Report to an employer information about an individual who is a member of the
workforce to the extent within the disease. 7. Report to an employer information about an individual who is a member of the
workforce to the extent within the worker’s compensation laws or similar programs.
To report abuse, neglect, or domestic violence: as required by law or with the patient’s agreement, the practice may inform government authorities if it is believed that a patient is the victim of abuse, neglect, or domestic violence.
To conduct health oversight activities: the practice may disclose your protected health information to a health oversight agency for use in audits, civil, administrative, or criminal investigations, proceedings, or actions, inspections, licensure or disciplinary actions, or other necessary oversight activities as permitted by law. However, if you are the subject of an investigation the practice will not disclose protected health information that is not directly related to you receipt of health care of public benefits.
Correctional Institution: should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health safety of other individuals. An inmate does not have the right to the Notice of Privacy Practices.
Law Enforcement: we may disclose health information for: law enforcement purposes as required by law, or in response to a valid subpoena. When needed to identify or locate a suspect, fugitive, material witness, or missing person. When needed to report of crime and when you are the victim of a crime in a specific limited instance.
The practice’s contact person(s) regarding the practice’s duties and your rights under HIPAA privacy regulation is the Privacy Officer. The Privacy Officer can provide information regarding issued related to the Notice by request. Complaints to the practice should be directed to the Privacy Officer(s) at our office:
Erica Boland 920 W Cty Hwy 16, Suite A West Salem, WI 54669 608-612-0777