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Privacy Policy

Your Health Care Information- Protecting Your Privacy
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.

Shoreview Pediatrics’ Responsibilities
It is your right as a patient to be informed of Shoreview Pediatrics’ legal duties with respect to protection of the privacy of your child’s personal health information.

Shoreview Pediatrics is required to:

  • Maintain the privacy of your child’s health information;
  • Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about your child; and
  • Abide by the terms of this notice.

Shoreview Pediatrics reserves the right to change the terms of the notice of privacy practices and make new notice provisions effective for all protected health information that it maintains. Shoreview Pediatrics also reserves the right to change the terms of its notice with respect to any applicable more limited uses and disclosures.

Shoreview Pediatrics will promptly revise and distribute its notice whenever Shoreview Pediatrics makes a substantial change to any of its privacy practices.

Shoreview Pediatrics will not use or disclose your child’s health information with your authorization, except as described in this notice.

YOUR HEALTH INFORMATION RIGHTS
You have the right to:

  • Request a restriction on certain uses and disclosures of your health information.
    You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or Shoreview Pediatrics’ payment or health care operation activities. However, Shoreview Pediatrics is not required to agree to your requested restriction. For example, if a member of your family is an employee of the clinic and your child receives health care services in the clinic, you may request that your child’s health care record not be maintained in the general record filing area.
  • Receive Confidential Communications.
    You have the right to request that Shoreview Pediatrics communicate your child’s heath information to you by alternative means or at alternative locations. Shoreview Pediatrics shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your child’s health care record.
  • Inspect and obtain a copy of your health record.
    You have the right to inspect and obtain a copy of your child’s health care record. This request for access to your child’s health care record must be submitted in writing to Medical Records. This right may not apply to certain types of psychotherapy notes and Shoreview Pediatrics may charge you a reasonable fee for a copy of your child’s health care record. For example, you may request a copy of your child’s health care record from your child’s physician.
  • Amend your health record.
    You have the right to request an amendment to your child’s health care record if you believe your child’s health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your child’s health record should be changed. If Shoreview Pediatrics did not create the health information you believe is incorrect or if Shoreview Pediatrics disagrees with you, Shoreview Pediatrics may deny your request. For example, if you believe that information in your child’s medical history is incorrect, such as your child’s birth date, you may request that this information be amended.
  • Obtain an accounting of disclosures of your health information.
    You have the right to an accounting of disclosures of your child’s health information that Shoreview Pediatrics has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. You will receive one accounting per year at no charge and Shoreview Pediatrics may charge you a reasonable fee for each subsequent request. For example, you may request an accounting of disclosures made from your child’s health record in the last year to the State for disease reporting.
  • Obtain a paper copy of the notice upon request.
    You have the right to obtain a paper copy of the notice upon request. For example, if you received the notice electronically, you may request that Shoreview Pediatrics provide a paper copy of the notice.

USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
Shoreview Pediatrics is permitted by the federal privacy rule to use or disclose your child’s protected health information for treatment, payment or health care operations.

Shoreview Pediatrics may use or disclose your health information for treatment.
Shoreview Pediatrics may use or disclose your child’s health information in the provision, coordination, or management of your child’s health care.

Example: Your child’s information may be disclosed from one physician to another if they are consulting each other in relation to your child’s care and treatment.

Example: Shoreview Pediatrics may use your child’s health information to provide you with an appointment reminder for your child’s next office visit.

Example: Shoreview Pediatrics may send you information about treatment alternatives or other health related services that may be of interest to you.

Shoreview Pediatrics may use or disclose your health information for payment.
Shoreview Pediatrics may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies your child, his/her diagnosis and treatment.

Example: Shoreview Pediatrics may use or disclose your child’s information to your insurer to obtain payment for the provision of health care services rendered to your child.

Shoreview Pediatrics may use or disclose your health information for routine health care operations.
Shoreview Pediatrics may use or disclose your child’s health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.

Example: Shoreview Pediatrics may review your child’s health record to determine the efficiency of the services provided to your child.

Example: Shoreview Pediatrics may contact you as part of a fundraising activity sponsored by your health care provider.

USES OR DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION PERMITTED WITHOUT YOUR AUTHORIZATION
Without your written authorization, Shoreview Pediatrics may use or disclose your child’s health information for the following purposes:

As Required by Law: Shoreview Pediatrics may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:

  • Disclosures about victims of elderly or child abuse;
  • Disclosures for judicial and administrative proceedings; or
  • Disclosures for law enforcement purposes.

Public health: As required by law, Shoreview Pediatrics may disclose your child’s protected health information to the State of Wisconsin for the purpose of statutory reporting.

Shoreview Pediatrics may disclose your child’s protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.

Shoreview Pediatrics may disclose your child’s protected health information excluding your HIV test result without your authorization to a county agency investigating child abuse.

Shoreview Pediatrics may disclose your child’s protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result without your authorization to the Food and Drug Administration (FDA).

Shoreview Pediatrics may disclose your child’s HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.

Shoreview Pediatrics may disclose your child’s protected health information that is reasonably related to a work related illness or injury if an application for workers’ compensation has been filed.

Victims of abuse, neglect or domestic violence:
Shoreview Pediatrics may disclose health information except for an HIV test result if Shoreview Pediatrics reasonably believes that an individual is a victim of child or elderly abuse.

Health oversight activities: Shoreview Pediatrics will not disclose HIV test results to health care oversight agencies without an authorization. Shoreview Pediatrics may disclose your child’s mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your child’s protected health information may be disclosed without your authorization to a state or federal agency.

Judicial and Administrative Proceedings: Shoreview Pediatrics may disclose your child’s protected health information in response to a court order. Shoreview Pediatrics may disclose your child’s protected health information in response to a subpoena if Shoreview Pediatrics is a party to a court action, Shoreview Pediatrics has received your authorization to disclose and has not complied within two business days or Shoreview Pediatrics failed to respond to a request for workers’ compensation records. Shoreview Pediatrics may disclose your child’s protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result in response to a subpoena from a state or federal agency.

Law Enforcement: Shoreview Pediatrics may disclose your child’s protected health information except for HIV test results to county law enforcement officials for the reporting and investigation of elderly and/or child abuse. Shoreview Pediatrics may disclose your child’s protected health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results to state and federal law officials. Shoreview Pediatrics may disclose mental health, alcohol or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. Shoreview Pediatrics may disclose your child’s protected health information to a law enforcement official in response to a court order.

FOR ACTIVITIES RELATED TO DEATH:
Coroner or Medical Examiner: Shoreview Pediatrics may use or disclose your child’s protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse or developmental disabilities to a coroner or medical examiner.

Funeral Director: Shoreview Pediatrics may use or disclose your child’s HIV test result to a funeral director.

For cadaveric organ, eye or tissue donation purposes: Shoreview Pediatrics may use or disclose your child’s HIV test result to an organ procurement organizations or other entities engaged in the procurement, banking, or transplantation or cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.

Research: Shoreview Pediatrics may use or disclose your child’s protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.

To avoid a serious threat to health or safety: Shoreview Pediatrics may disclose your child’s protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.

Disclosures for specialized government functions: Shoreview Pediatrics may disclose protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result for national security, for protection of the President and for medical suitability determination or of Armed Forces personnel to a state or federal agency.

Shoreview Pediatrics may disclose protected health information to limited staff of a correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.

Workers Compensation: Shoreview Pediatrics may disclose protected health information reasonably related to a workers’ compensation injury.

Shoreview Pediatrics has attempted to explain with this notice the circumstances where state law may be more protective than the federal privacy rule and provides greater privacy protection.

Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your child’s health information requires Shoreview Pediatrics to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to Shoreview Pediatrics’ Privacy Officer.

PATIENT COMPLAINT PROCESS
If you believe your privacy rights have been violated, you may file a complaint with Shoreview Pediatrics or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint.

To file a complaint with Shoreview Pediatrics please contact the Shoreview Pediatrics’ Privacy Officer who will provide you with the necessary assistance.

QUESTIONS OR CONCERNS
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:

Gail Oninski, Administrator
Shoreview Pediatrics
2524 E. Webster Place, Suite 301
Milwaukee, WI 53211
(414) 272-7009

Effective Date: This Notice of Privacy Practice is effective as of April 14, 2003.