HIPAA

 ~~ 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. Our pledge regarding health information: We  understand that health information about you is personal. We are  committed to protecting the privacy of your health information by  complying with all applicable federal and state privacy and  confidentiality laws. During your treatment doctors, nurses, and other  caregivers may gather information about your medical history and your  current health. This notice explains how that information may be used  and shared with others. It also explains your privacy rights regarding  this kind of information. The terms of this notice apply to health  information created or received by Stockholm Health Care Clinic. We are  required by law to: make sure that medical information that identifies  you is kept private; give you this notice of our legal duties and  privacy practices with respect to medical information about you; follow  the terms of the notice that is currently in effect; and notify you in  the event there is a breach of any unsecured protected health  information about you. Your medical information may be used and  disclosed for the following purposes: •Treatment: We may use your  information to provide, coordinate, and manage your care and treatment.  For example, our physicians may share your medical information with  another physician for a consultation or a referral. We will get your  written consent prior to making disclosures outside of Stockholm Health  Care Clinic for treatment purposes, except in emergency circumstances  when it is not possible to get your consent. •Health Care Operations:  We may use and disclose medical information about you for the health  care operations of Stockholm Health Care Clinic .Health care operations  are the uses and disclosures of information that are necessary to run  this practice and to make sure that all of our patients receive quality  care. For example, we may use medical information to review our  treatment and services, and to evaluate the performance of our staff and  providers in caring for you. We will get your written consent before  making disclosures to others outside of Stockholm Health Care Clinic for  health care operations purposes. •Electronic Health Record: We use an  electronic health record that allows care providers at Stockholm Health  care Clinic to store, update and use your health information as needed  to provide care. We do this so it is easier for your providers to access  your health information when you are seeking care at more than one of  our locations and to better coordinate and improve the quality of your  care. If you receive care from more than one provider who uses the  common electronic health record, your health information will be  combined into one record. This electronic health record is a secure  system maintained by Stockholm Health Care Clinic. •Appointment  Reminders and Other Health Information: We may use your medical  information to send you reminders about future appointments. We may also  send you refill reminders or other communications about your current  medications. However, if we receive any financial remuneration for  making such refill or medication communications beyond our costs of  making the communication, we must first obtain your written  authorization to make such communications. We may contact you with  information about new or alternative treatments, health related benefits  and healthcare services or for purposes of care coordination, unless we  receive financial remuneration in exchange for making the  communication; in that case, we will obtain your written authorization  to make such communications. However, we are not required to obtain your  written authorization for face-to-face communications. .•To People  Assisting in Your Care: Stockholm Health Care Clinic will only disclose  medical information to those taking care of you, helping you to pay your  bills, or other close family members of friends if these people need to  know this information to help you, and then only to the extent  permitted by law. We may, for example, provide limited medical  information to allow a family member to pick up a prescription for you.  Generally, we will get your written consent prior to making disclosures  about you to family or friends. If you are able to make your own health  care decisions, Stockholm Health Care Clinic will ask your permission  before using your medical information for these purposes. If you are  unable to make health care decisions, Stockholm Health Care Clinic will  disclose relevant medical information to family members or other  responsible people if we feel it is in your best interest to do so,  including in an emergency situation. •Research: By performing research,  we learn new and better ways to diagnose and treat illnesses. Federal  law permits Stockholm Health care Clinic to use and disclose medical  information about you for research purposes, either with your specific,  written authorization or when the study has been reviewed for privacy  protection by an Institutional Review Board or Privacy Board before the  research begins. In some cases, researchers may be permitted to use  information in a limited way to determine whether the study or the  potential participants are appropriate. Wisconsin law generally requires  that we get your consent before we disclose your health information to  an outside researcher. We will make a good faith effort to obtain your  consent or refusal to participate in any research study, as required by  law, prior to releasing any identifiable information about you to  outside researchers. •As Required by Law: We will disclose medical  information about you when we are required to do so by federal, state or  local law. •To Avert a Serious Threat to Health or Safety: We may use  and disclose medical information about you when necessary to prevent a  serious threat to your health and safety or the health and safety of the  public or another person. Any disclosure must be only to someone able  to help prevent the threat. In addition, Wisconsin law generally does  not permit these disclosures unless we have your written consent, or  when the disclosure is specifically required by law, including the  limited circumstances in which Stockholm Health Care Clinic health care  professionals have a “duty to warn.” •To Business Associates: Some  services are provided by or to Stockholm Health Care Clinic through  contracts with business associates. Examples include, attorneys,  consultants, collection agencies, and accreditation organizations. We  may disclose information about you to our business associate so that  they can perform the job we have contracted with them to do. To protect  the information that is disclosed, each business associate is required  to sign an agreement to appropriately safeguard the information and not  to redisclose the information unless specifically permitted by law.  Other Uses and Disclosures of Protected Health Information •We are  required to obtain a written authorization from you for most uses and  disclosures of protected health information for marketing purposes and  disclosures that constitute a sale of protected health information.  Except as described in this Stockholm Health Care Clinic will not use or  disclose your protected health information without a specific written  authorization from you. If you provide us with this written  authorization to use or disclose medical information about you, you may  revoke that authorization, in writing, at any time. If you revoke your  authorization, we will no longer use or disclose medical information  about you for the reasons covered by your written authorization, except  to the extent we have already relied on your authorization. We are  unable to take back any disclosures we have already made with your  permission, and we are required to retain our records of the care that  we provided to you. Your medical information may be released in the  following special situations without an authorization: •Organ and  Tissue Donation: We may release your medical information to  organizations that handle organ procurement or organ, eye or tissue  transplantation, or to an organ donation bank, as necessary to  facilitate organ or tissue donation and transplantation. The information  that Stockholm Health Care Clinic may disclose is limited to the  information necessary to make a transplant possible. •Military and  Veterans: If you are a member of the armed forces, we will release  medical information about you as requested by military command  authorities if we are required to do so by law, or when we have your  written consent. We may also release medical information about foreign  military personnel to the appropriate foreign military authority as  required by law or with written consent. •Workers’ Compensation: We may  release medical information about you for workers’ compensation or  similar programs. These programs provide benefits for work-related  injuries or illness. We are permitted to disclose information regarding  your work related injury to your employer or your employer’s workers’  compensation insurer without your specific consent, so long as the  information is related to a workers’ compensation claim. •Public  Health: We may disclose medical information to public health authorities  about you for public health activities. These disclosures generally  include the following: - Preventing or controlling disease, injury or  disability; - Reporting births and deaths; - Reporting child abuse or  neglect, or abuse of a vulnerable adult; - Reporting reactions to  medications or problems with products; - Notifying people of recalls of  products they may be using; - Notifying a person who may have been  exposed to a disease or may be at risk for contracting or spreading a  disease or condition; or - Reporting to the FDA as permitted or required  by law. •Health Oversight Activities: Stockholm Health care Clinic may  disclose medical information to a health oversight agency for health  oversight activities that are authorized by law. These oversight  activities include, for example, government audits, investigations,  inspections, and licensure activities. These activities are necessary  for the government to monitor the health care system, government  programs, and compliance with civil rights laws. Minnesota law requires  that patient identifying information (for example, your name, social  security number, etc.) be removed from most disclosures for health  oversight purposes, unless you have provided us with written consent for  the disclosure. •Lawsuits and Disputes: We may disclose medical  information about you in response to a valid court order or statutory  authorization, or with your written consent. •Law Enforcement: We may  release medical information if asked to do so by a law enforcement  official in response to a valid court order, grand jury subpoena, or  warrant, or with your written consent. In addition, we are required to  report certain types of wounds, such as gunshot wounds and some burns.  In most cases, reports will include only the fact of injury, and any  additional disclosures would require your consent or a court order. We  may also release information to law enforcement that is not a part of  the health record (in other words, non-medical information) for the  following reasons: - To identify or locate a suspect, fugitive, material  witness, or missing person; - If you are the victim of a crime, if,  under certain limited circumstances, we are unable to obtain your  agreement; - About a death we believe may be the result of criminal  conduct; - About criminal conduct at our facility; and - In emergency  circumstances to report a crime; the location of the crime or victims;  or the identity, description or location of the person who committed the  crime. •Coroners, Medical Examiners, and Funeral Directors: We will  release medical information to a coroner or medical examiner in the case  of certain types of death, and we must disclose health records upon the  request of the coroner or medical examiner. This may be necessary, for  example, to identify you or determine the cause of death. We may also  release the fact of death and certain demographic information about you  to funeral directors as necessary to carry out their duties. Other  disclosures from your health record will require the consent of a  surviving spouse, parent, person appointed by you writing or your  legally authorized representative. •National Security and Intelligence  Activities: We will release medical information about you to authorized  federal officials for intelligence, counter-intelligence, and other  national security activities only as required by law or with your  written consent. •Protective Services for the President and Others: We  will disclose medical information about you to authorized federal  officials so they may provide protection to the President, other  authorized persons, or foreign heads of state, or conduct special  investigations only as required by law or with your written consent.  •Inmates: If you are an inmate of a correctional institution or under  the custody of a law enforcement official, we will release medical  information about you to the correctional institution or law enforcement  official only as permitted by law or with your written consent. You  have the following rights regarding medical information we maintain  about you: •Right to Inspect and Copy: You have the right to inspect  and receive a copy of your medical information that is used to make  decisions about your care. Usually, this includes medical and billing  records maintained by Stockholm Health Care Clinic If you wish to  inspect and copy medical information, you must submit your request in  writing to Attention: Stockholm Health Care Clinic W12070 State Hwy 35,  Stockholm, WI 54769 If you request a copy of the information, we may  charge a reasonable fee for the costs of copying, mailing, or other  supplies associated with your request, to the extent permitted by state  and federal law. If we maintain your health information electronically  as part of a designated record set, you have the right to receive a copy  of your health information in electronic format upon your request. You  may also direct us to transmit your health information (whether in hard  copy or electronic form) directly to an entity or person clearly and  specifically designated by you in writing. We may deny your request to  inspect and copy your information in certain very limited circumstances.  For example, we may deny access if your provider believes it will be  harmful to your health, or could cause a threat to others. In these  cases, we may supply the information to a third party who may release  the information to you. If you are denied access to medical information,  you may request that the denial be reviewed. Another licensed health  care professional chosen by Stockholm Health Care Clinic will review  your request and the denial. The person conducting the review will not  be the person who denied your request. We will comply with the outcome  of the review. •Right to Request Amendment: If you believe that medical  information we have about you is incorrect or incomplete, you have the  right to ask us to change the information. You have the right to request  an amendment for as long as the information is kept by or for Stockholm  Health Care Clinic. To request a change to your information, your  request must be made in writing and submitted to the above address. In  addition, you must provide a reason that supports your request.  Stockholm Health Care Clinic may deny your request for an amendment if  it is not in writing or does not include a reason to support the  request. In addition, we may deny your request if you ask us to amend  information that: - Was not created by Stockholm Health Care Clinic,  unless the person or entity that created the information is no longer  available to make the amendment; - Is not part of the medical  information kept by or for Stockholm Health Care Clinic - Is not part of  the information which you would be permitted to inspect and copy; or -  Is accurate and complete. •Right to an Accounting of Disclosures: You  have the right to request an “accounting of disclosures.” This is a list  of the disclosures we made of medical information about you. This list  will not include disclosures for treatment, payment, and health care  operations; disclosures that you have authorized or that have been made  to you; disclosures for facility directories; disclosures for national  security or intelligence purposes; disclosures to correctional  institutions or law enforcement with custody of you; disclosures that  took place before November 10, 2013; and certain other disclosures. To  request this list of disclosures, you must submit your request in  writing to the above address. Your request must state a time period for  which you would like the accounting. The accounting period may not go  back further than six years from the date of the request, and it may not  include dates before November 10, 2013. You may receive one free  accounting in any 12-month period. We will charge you for additional  requests. •Right to Request Restrictions: You have the right to request  a restriction or limitation on the medical information we use or  disclose about you. If you pay out-of-pocket in full for an item or  service, then you may request that we not disclose information  pertaining solely to such item or service to your health plan for  purposes of payment or health care operations. We are required to agree  with such a request, unless you request a restriction on the information  we disclose to a health maintenance organization (“HMO”) and the law  prohibits us from accepting payment from you above the cost-sharing  amount for the item or service that is the subject of the requested  restriction. However, we are not required to agree to any other request.  If we do agree, we will comply with your request unless the information  is needed to provide you emergency treatment or you request that we  remove the restriction. To request restrictions, you must make your  request in writing to the above address, your request, you must tell us  (1) what information you want to limit; (2) whether you want to limit  our use, disclosure, or both; and (3) to whom you want the limits to  apply, for example, if you want to prohibit disclosures to your spouse.  •Right to Request Confidential Communications: You have the right to  request that we communicate with you about medical matters in a certain  way or at a certain location. For example, you can ask that we only  contact you only at work or only by mail. To request confidential  communications, you must make your request in writing to the above  address. We will not ask you the reason for your request. We will  accommodate all reasonable requests. Your request must specify how or  where you wish to be contacted, and we may require you to provide  information about how payment will be handled. •Right to a Paper Copy  of This Notice: You have the right to receive a paper copy of this  notice. You may ask us to give you a copy of this notice any time. This  notice is on our websites at www.stockholmhealthcareclinic.com •Others  Acting on Your Behalf: These rights may also be exercised by someone who  has the legal right to act on your behalf. WHO WILL FOLLOW THIS NOTICE:  All of our employees, volunteers, and agents will comply with the terms  of this notice. Changes to This Notice The effective date of this  notice is November 10, 2013. We reserve the right to change this notice.  We reserve the right to make the revi