Every aspect of your health information is important, and ensuring that it remain private remains a top priority at Mequon Clinical Associates. This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully and should you have any questions do not hesitate to contact us for clarification.
OUR LEGAL DUTY: We are required by federal and state law to maintain the privacy of your health information. We are also required to inform you of this Notice about our privacy practices, our legal duties, and your rights concerning your healthcare information. As a result of the Federal Health Insurance Portability and Accountability Act (HIPPA) regulations, this Notice took effect April 14, 2003. Mequon Clinical Associates has always followed, and continues to follow, Wisconsin privacy protection regulations for state-certified outpatient mental health clinics.
CONSENT FOR TREATMENT: Once you sign our Consent for Treatment Form, we use your healthcare information for your treatment, payment and or healthcare operations. Examples of these are:
TREATMENT: Disclosure of your healthcare information to another healthcare provider who is providing treatment to you.
PAYMENT: Disclosure of your healthcare information to obtain payment for services we provide to you.
HEALTHCARE OPERATIONS: Refers to quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, accreditation, certification, licensing or credentialing activities.
OTHER CONSENT FORMS: Before we can use your healthcare information for any purposes, other than those sited above, we must obtain a signed consent from you on a form different from the Consent For Treatment Form, specifying the purpose and parameters of that release.
LEGAL DISCLOSURES: Occasionally we are required by law to release healthcare information even if we do not have a client’s signed consent to do so. We are required to do this when we suspect a serious threat to your safety, the safety of another individual or the safety of the general public. At times we are required to release information for certain legal proceedings. If possible, we do legal releases only with your knowledge and written consent.
YOUR LEGAL RIGHTS: You may revoke signed consent forms at any time in writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
ACCESS: You have the right to look at or get copies of your billing records and health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. You must make a request in writing to obtain access to your health information. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request copies, we will charge you 50 cents for each page to cover staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. To contact us, use the information listed at the end of this Notice.
RESTRICTIONS: When you sign the Consent For Treatment Form, you have the right to request that we place additional restrictions on your use or disclosure of your health information. We are not required to agree to these additional restrictions; however, if we do, we will abide by your agreement, except in emergencies, unlawful requests, or if the information is necessary to treat you.
ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make that request in writing. Your request must specify the alternative means or location and provide satisfactory explanation and how payments will be handled under the alternative means or location you request.
AMENDMENT: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny you request under certain circumstances.
QUESTIONS AND COMPLAINTS: If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, disagree with a decision we made about access to your health information, our response to a request you made to amend or restrict the use or disclosure of your health information, or to have us communicate with you about alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. Filing a complaint with us or with the U.S. Department of Health and Human Services will not affect the quality of services you receive from us.
Contact Officer: Cari Noha
Privacy Officer: Jeffrey Taxman
Mequon Clinical Associates, SC
1045 W. Glen Oaks Lane, Suite 1
Mequon, WI, 53092