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.
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.
Responsibilities of Turville Bay MRI and Radiation Oncology Center
It is your right as a patient to be informed of Turville Bay’s legal duties with respect to protection of the privacy of your personal health information.
Turville Bay MRI and Radiation Oncology Center is required to:
- Maintain the privacy of your health information,
- Provide you with a notice of legal duties and privacy practices regarding protected health information collected and maintained about you, and
- Abide by the terms of this notice.
Turville Bay reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. Turville Bay also reserves the right to change the terms of its notice with respect to any applicable more limited uses and disclosures.
Turville Bay will promptly revise and distribute its notice whenever Turville Bay makes a substantial change to any of its privacy practices.
Turville Bay will not use or disclose your health information without 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 Turville Bay’s payment or health care operation activities. However, Turville Bay is not required to agree to your requested restriction.
Restrict certain disclosures to a health plan for self pay items or services. You have a right to restrict disclosure of protected health information to a health plan if you pay out of pocket in full for the health care item or service provided.
Receive confidential communications. You have the right to request that Turville Bay communicate your health information to you by alternative means or at alternative locations. Turville Bay 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 health care record.
Inspect and obtain a copy of your health record. You have the right to inspect and obtain a copy of your health care record. You also have a right to an electronic copy of your record. Turville Bay may charge you a reasonable fee for a copy of your health care record.
Amend your health record. You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. This request must be submitted in writing and state the reason you health record should be changed. If Turville Bay did not create the health information you believe is incorrect or if Turville Bay disagrees with you, Turville Bay may deny your request. For example, if you believe that information in your medical history is incorrect, such as your 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 health information that Turville Bay 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 may receive one accounting per year at no charge, and Turville Bay may charge you a reasonable fee for each subsequent request.
Receive notice of a breach of unsecured protected health information. You have a right to and will receive notification following a breach of unsecured protected health information.
Obtain a paper copy of the notice upon request. You have the right to obtain a paper copy of this notice upon request. For example, if you received the notice electronically, you may request that Turville Bay provide a paper copy of the notice.
Uses and Disclosures of Your Protected Health Information for Treatment, Payment and Health Care Operations
Turville Bay is permitted by the federal privacy rule to use and disclose your protected health information for treatment, payment, or health care operations.
Turville Bay may use or disclose your health information for treatment. Turville Bay may use or disclose your health information in the provision, coordination of, or management of your care. Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
Turville Bay may use or disclose your health information for payment. Turville Bay may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis, and your treatment. Example: Turville Bay may use or disclose your information to your insurer to obtain payment for the provision of health care services.
Turville Bay may use or disclose your health information for health care operations. Turville Bay may use or disclose your health information for evaluation of patient care services, patient safety activities, evaluating the performance of health care providers, activities relating to compliance with the law, and business planning and development.
- Turville Bay may review your health record to determine the efficiency of the services provided to you.
- Turville Bay may use your protected health information to send appointment reminders to you or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Uses or Disclosures of Your Protected Health Information Subject to Your Right to Object
Without your written authorization, Turville Bay may use or disclose your health information for the following purposes, subject to your right to object.
Persons involved in your care or payment for you care. Turville Bay may release protected health information about you to a family member, friend, or someone you designate who is involved in your care or payment of your care. Turville Bay may also disclose your health information to an entity authorized to assist in disaster relief so that those who care for you can receive information about your location and status.
Fundraising Activities. Turville Bay may use limited information, as specified in the law, to contact you in the future to raise money for Turville Bay. You have the right to opt out of any fundraising communications at any time by contacting the Privacy Officer. (Contact Information provided below.)
Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization
Without your written authorization, Turville Bay may use or disclose your health information for the following purposes:
As required by law: Turville Bay will use or disclose protected health information to the extent that the use of disclosure is required by law and will be limited to the relevant requirements of the law. Uses or disclosures required by the 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, and
- Disclosures for law enforcement purposes.
Public Health: As required by law, Turville Bay will disclose your protected health information to the State of Wisconsin for the purpose of statutory reporting. Examples:
- Turville Bay is required to report certain types of cancers to the Department of Health and Family Services under the Wisconsin Cancer Reporting System.
- Turville Bay may disclose your protected health information to a state of federal public health agency for the purpose of preventing or controlling disease, injury, or disability.
- Turville Bay may disclose your protected health information to a county agency investigating child abuse.
- Turville Bay may disclose your protected health information to the Food and Drug Administration (FDA).
- Turville Bay may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.
Victims of abuse, neglect, or domestic violence: Turville Bay may disclose health information if Turville Bay reasonably believes that an individual is a victim of child or elderly abuse.
Health oversight activities: Turville Bay may disclose you protected health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings authorized by law.
Judicial and Administrative Proceedings: Turville Bay may disclose your protected health information in the course of an administrative or judicial proceeding.
Law Enforcement: Turville Bay may disclose your protected health information to law enforcement officials in response to a court order or similar process allowed by law in order to identify or locate a suspect, fugitive, material witness or missing person, or to report or respond to a crime.
Coroner or Medical Examiner: Turville Bay may use or disclose your protected health information to a coroner or medical examiner to identify a deceased person or determine a cause of death.
For cadaveric organ, eye, or tissue donation purposes: Turville Bay may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye, or tissue donation and transplantation.
Research: Turville Bay may use or disclose your 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: Turville Bay may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.
Disclosures for specialized government functions: Turville Bay may disclose protected health information for national security, for protection of the President, and for medical suitability determination or of Armed Forces personnel to state or federal agency.
Turville Bay 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: Turville Bay may disclose protected health information related to workers’ compensation injury.
Other Uses of Your Protected Health Information:
Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization.
In any situations not covered by this notice as noted above, we will ask for your written authorization before using or disclosing information about you. You may withdraw your authorization at any time by notifying us in writing of your decision.
Patient Complaint Process
If you believe your privacy rights have been violated, you may file a complaint with the Turville Bay Privacy Officer whose contact information is noted below. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services Office of Civil Rights.
Turville Bay cannot, and will not, require you to waive the right to file a complaint as a condition of receiving treatment or retaliate against you for filing a complaint.
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:
Turville Bay MRI and Radiation Oncology Center
1104 John Nolen Drive
Madison, WI 53713
This Notice of Privacy Practices is effective as of May 1, 2013