NOTICE OF PRIVACY PRACTICES
REGARDING PROTECTED HEALTH INFORMATION
This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
This notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA), which went into effect on April 14, 2003. It describes how we may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information except when the release is required or authorized by law, contract or regulation.
Acknowledgement of receipt of this notice
You will be asked to provide a signed receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your protected health care services will in no way be conditioned upon your signature. If you decline to sign the Notice of Privacy Practice Receipt, we will continue to serve you and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.
Our Legal Duty
"Protected health information" is individually identifiable protected health information. This information is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains demographic information about you, the provider of service, dates of service, medications, diagnosis, diagnostic tests, symptoms and any other relevant demographic information needed for current treatment. Protected health information also includes mental health/AODA psychotherapy notes, assessments, progress notes or discharge summaries. These documents require additional informed consent in order to be released or disclosed and are not held within the "designated record set."
Brown County is required by law to do the following:
- Ensure your protected health information is kept private
- Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information
- Follow the terms of the notice currently in effect
- Communicate changes in the notice
Required Uses and Disclosures of Your Protected Health Information
Brown County will use and disclose protected health information about you for treatment, payment and health care operations. This may include diagnosis, treatment, personal address and other identifying information.
By law, we are able to use or disclose your protected health information, held within your designated record set, without your authorization for the following purposes:
Treatment
Brown County will use your protected health information to provide you treatment, determine functional eligibility and/or to provide services. For example, we may consult with internal, contract or other business associate professionals to provide them with information they need to make decisions about your care or services.
Payment
In some cases Brown County may use your protected health information in order to receive reimbursement from third party payers for services provided.
Health Care Operations
Brown County may use and disclose your protected health information for regular service operations or to detect and prevent health care fraud or abuse. Regular service operations include quality assessment, improvement activities, certification, licensing or credentialing activities. There are some services provided in our organization through contracts with business associates or service providers. When these services are contracted, we may disclose your personal protected health information to our business associates so they can perform the job we've asked them to do. To protect your protected health information, however, we require the business associate to be subject to the federal privacy rules so they can appropriately safeguard your information. We will not sell your protected health care information to anyone.
Disaster Relief
Brown County may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and can disclose to family or individuals involved in your health care.
Communications to You
Brown County may use your information to communicate appointment reminders or to request additional information. These communications may be by phone, mail or other means at your request. We also may contact you with information about programs or services that may be of interest to you or that can improve your health. A survey may be mailed to you after your visit.
Required or Permitted By Law
In certain circumstances we may report some of your protected health information to legal entities such as law enforcement officials or government agencies. We may disclose your information in response to a court order or for certain types of administrative proceedings where the law permits or requires us to disclose information.
Public Health Reasons
We may disclose your protected health information to a public health authority that is permitted by law to collect or receive the information. This information may be used to prevent or control disease, injury or disability. The agency is committed to protecting and reporting potential abuse of children, vulnerable adults or at risk elders.
Health Oversight Activities
We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights authorities.
Death Records
We may disclose your protected health information to coroners, medical examiners, and funeral directors, as required or permitted by law, so they can carry out their duties related to your death.
Organ Donation
We may disclose your protected health information to entities involved in obtaining, banking or transplanting organs, eyes or tissue for donation or transplantation purposes.
Research
We may disclose your protected health information to researchers only when approved or authorized by law.
Health and Safety Threat
We may disclose your protected health information to the necessary authorities if we believe in good faith that such use or disclosure is necessary to prevent or minimize a serious or imminent threat to you or the public's health or safety.
Incarceration, Law Enforcement Custody and National Security
We may disclose your protected health information if you are in the custody of law enforcement officials or an inmate in a correctional institution or a threat to national security.
Workman's Compensation
We may disclose your protected health information to the appropriate persons in compliance with workers' compensation laws. For example, your employer may be provided with information about your work related injury.
Communication with Family and Friends
If you are not physically available or cognitively able to grant informal permission, we are permitted to use our professional judgment to determine whether disclosing is in your best interest and determine you would otherwise allow such a disclosure. We may disclose your protected health information (but not in written record form) to your family, friend or other person identified by you and involved in your care.
On Your Authorization
You may give us written or verbal authorization to use your protected health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it verbally or in writing at any time. Unless you give us written or verbal permission, Brown County cannot use or disclose your protected health information for any reason except those allowable by law, contract or regulation. All other disclosures of your personal health care information will require an authorization by you.
Your Rights Regarding Protected Health Care Information:
Inspect or Obtain a Copy of Your Protected Health Care Information
You may inspect and obtain a copy of your protected health information that is contained in your "designated record set" for as long as we maintain the protected health information. A fee may be charged for the cost of copying, mailing and other related supplies. Should you request additional supplemental information from outside of your designated record set (mental health, AODA assessments or progress notes), a written request or additional releases may apply.
Right to Request Restrictions
You have the right to request restrictions on how your protected health information is used or to whom your protected health care information is disclosed for any of the following situations: treatment, payment, health care operations, notification or communication to family or friends, and disclosure to disaster relief agencies. Your request must be in writing to the Privacy Officer when you wish the restriction to be instituted. In your request, you must inform us 1) what information you want restricted; 2) whether you want to restrict our use, disclosure or both; 3) to whom you want the restriction to apply, for ex. disclosures to your spouse; and 4) an expiration date. We are not required to agree in all circumstances to your request for the restriction. While we will consider your request, because of the number, complexity and nature of services we provide, we may not be able to grant your request.
Right to Request Amendments
You do not have the right to change your protected health information. You have the right to request that we clarify your protected health information by adding information to your records. Your request must be in writing, must explain why the information should be amended and be sent to our Privacy Officer. Brown County has the right to deny your request. The denial will be in writing. You may respond with a statement in writing as to why you disagree with the decision and it will be added to the record. If we agree to amend the records as requested, then we may also make reasonable efforts to inform others, including specific parties named by you, of the changes.
Accounting of Disclosures
Brown County must keep a record of who your protected health information is disclosed to. You have the right to see the disclosure record. You may request this information from the Privacy Officer.
Confidential Communications
You may request that we communicate with you using alternative means or at an alternative location. For example, you may request that we only call you at your work phone number or that we never leave a voice mail at your home. We will accommodate reasonable requests when possible.
Complaints
If you believe these privacy rights have been violated, you may present in person, call, or file a written complaint with the county. Your complaint will not affect the care and service we provide to you in the present or in the future.
Contact Information for Privacy Officers:
Brown County Health Department
Health Director
610 S. Broadway Street
Green Bay, WI 54303
920-448-6400
Brown County Human Resources
Human Resources Manager
305 E. Walnut Street,
Green Bay, WI 54301
920-448-4071
Brown County Human Services
Health Information Manager
3150 Gershwin Drive
Green Bay, WI 54311
920-391-4760
Director of Community Programs
111 N. Jefferson Street
Green Bay, WI 54301
920-448-6003
Brown County Jail
Jail Lieutenant
3030 Curry Lane
Green Bay, WI 54311
920-391-6808
Region V - Chicago (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin)
Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Voice Phone (312)886-2359
FAX (312)886-1807
TDD (312)353-5693
Effective Date: April 2003
Revised Date: November 2013
