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

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This notice applies to Lakeview Health Center and its staff, volunteers, and students.  This notice also applies to other health care providers that come to Lakeview Health Center to care for residents, such as physicians, nurse practitioners and lab personnel. These providers may have different privacy practices in their offices but will follow Lakeview Health Center’s privacy practices while providing care for you at Lakeview Health Center.  

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:

• Basis for planning your care and treatment
• Means of communication among the health professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party (insurance company) can verify that services billed were actually provided
• A tool in educating health professionals
• A source of data for facility planning and marketing
• 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 Lakeview Health Center, the information belongs to you.  You have the right to:

• Request a restriction on certain uses and disclosures of your information with the understanding that Lakeview is not required to agree to a requested restriction.
• Obtain a paper copy of the Notice of Information Practices upon request
• Inspect and obtain a copy of your health record 
• Request to amend your health record.  Lakeview Health Center requires that any requests for amendment of protected health information be made in writing and include supporting documentation for the amendment.  This request is to be sent to Privacy Officer, Lakeview Health Center, 902 Garland Street E., West Salem, WI  54669.  Lakeview Health Center reserves the right to disallow requests for amendment that do not meet criteria.
• Obtain an accounting of disclosures of your health information
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken
• Request communications of your health information by alternative means or at alternative locations.  This request must be in writing and submitted to the Privacy Officer.  Lakeview Health Center reserves the right to disallow requests for alternative confidential communications that do not meet criteria.

Lakeview Health Center Responsibilities

Lakeview Health Center is required to:

• Maintain the privacy of your health information
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• Abide by the terms of this notice
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable request you may have to communicate health information by alternative means or to alternative locations

We reserve the right to change our practices and to make new provisions effective for all protected health information we maintain.  Should our information practices change, we will post a revised notice within the facility, make revised notices available upon request and post revised notices to our web site at:

http://www.co.la-crosse.wi.us/Departments/lakeview

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 at 608-786-1400, extension 171.

If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services.  There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations 

Lakeview Health Center is permitted by law to use and disclosure protected health information in the following ways:

• Treatment:  We will use your health information for purposes of treatment.

For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine your course of treatment.  Your physician will document in your record expectations of the members of your healthcare team.  Nurses and other members of your healthcare team will then record the actions they took and their observations.  In that way, the physician will know how you are responding to treatment.

We will also provide your physician or healthcare provider with copies of various reports that will assist him or her in treating you once you are discharged from Lakeview Health Center.

We will share your protected health information with members of your treatment team.  This may include but is not limited to, physicians, lab and x-ray personnel, hospital and emergency providers (should you be transferred to a hospital) rehabilitation therapy (physical therapy, occupational therapy, speech therapy), pharmacy, dental and eye care providers.  

• Payment of Claims:  We will use your health information for payment of claims.

For example:  A bill may be sent to you or a third-party payer (insurance company).  The information on or included with the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.   Information from your medical record may be sent to your insurance carrier and associated medical review agencies in order to get your bill paid.  

Additionally, Lakeview Health Center may provide protected health information to contracted vendors and or business associates that perform services on behalf of Lakeview Health Center, (i.e. lab, pharmacy, rehabilitation therapy, x-ray and mobile diagnostic services), to facilitate payment of claims for services these vendors/associates provided to you.

• Carry out Healthcare Operations:  We will use your health information for regular health care operations. 

For example:  Lakeview Health Center staff, members of quality improvement teams, other committees, and outside agencies may review information in your health record to assess the care and outcomes in your case and others like it.  This information will be used in an effort to continually improve the quality and effectiveness of the healthcare services we provide. 

Business Associate:  Some services at Lakeview Health Center are provided through contracts with business associates.  Examples include, pharmacy management, utilization review, transcription and billing services.  We may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered.  To protect your health information, however, we require the business associate to appropriately safeguard your information. 

Directory:  Unless you notify us that you object, we will use your name, location in the facility, birthday, and personal information for directory and internal activity purposes.  This information may be provided to people who ask for you by name. This directory information, which includes name and unit, is posted at the front entrance and your name is indicated on your room door.  Your name and religious affiliation will be shared with members of the clergy. 

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, legal guardian, or another person responsible for your care, your location and general condition. 

• As required by law or court order:  For example: 

Coroners/Medical Examiners:  We may disclose health information to these agencies consistent with applicable law to carry out their duties.

Funeral Directors:  We may disclose health information needed for completion of the death certificate or other legally required documents, consistent with applicable law.

Organ Procurement Organizations:  Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Food and Drug Administration (FDA):  We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers Compensation:  We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health:  As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Health Care Oversight:  As required by law, we may disclose your health information to state/federal government agencies that may audit, investigate, inspect or license Lakeview Health Center.  We will also disclosure your information as mandated by law for investigation of abuse, neglect and review of civil rights.

To avoid a serious threat to health or safety:  As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public’s health or safety.

Military, National Security, Incarceration, Law Enforcement:  Your health information may be disclosed to authorities involved under the above circumstances.  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 and safety or other individuals.  We may disclose health information for law enforcement purposes as required by law or in response to a court order.

Court Ordered Review:  We may disclose health information as required by an authorized court order.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member of business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Any uses and disclosures of your health information other than generally described above will only be made with your individual written authorization, which you may revoke at any time.

Effective:  4-14-2003 

Revised:  10-7-2003

LHC 271/FEB 03