Patient Information

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DONALD R. GORE, M.D.
D. SCOTT SELLINGER, M.D.
KEVIN J. GASSNER, M.D.
SCOTT T. GLAESER, M.D.
BRUCE A. VAN DOMMELEN, M.D.

NOTICE OF PRIVACY PRACTICES

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.

1. Sheboygan Orthopaedic Associates is required by law to maintain the privacy of protected health information. Sheboygan Orthopaedic Associates is further required to provide individuals with notice of its legal duties and privacy practices with respect to protected health information. Its legal duties and privacy practices are described in this Notice.

2. Sheboygan Orthopaedic Associates will abide by the terms of this Notice or the Notice currently in effect at the time of the disclosure.

3. Sheboygan Orthopaedic Associates reserves the right to change the terms of its Notice and to make new Notice provisions effective for all protected health information that it maintains. A revised copy will be available at the office at a patient's next visit and on our website.

4. Sheboygan Orthopaedic Associates may use and disclose protected health information for treatment, payment and health care operations without an individual's written consent.
Examples of treatment include, but are not limited to, providing, coordinating, or managing health care and related services by one or more health care providers; consultations between health care providers concerning a patient; referrals to nursing homes, foster care homes, or home health agencies; and/or referrals to other providers for treatment.
Payment activities include, but are not limited to, activities undertaken by Sheboygan Orthopaedic Associates to obtain reimbursement for services provided; determining eligibility or coverage; managing claims and collection activities; reviewing health care services (by a third party payor or claims administrator) with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; and obtaining precertification and preauthorization of services.
Health care operations include, but are not limited to, conducting quality assessment and improvement activities; conducting outcomes evaluation and development of clinical guidelines; protocol development, case management, or care coordination; contacting health care providers and patients with information about treatment alternatives; conducting or arranging for medical review, legal services, and auditing functions; conducting chart audits in accordance with compliance directives; and business management and general administrative activities of Sheboygan Orthopaedic Associates. Health care operations may be conducted by Sheboygan Orthopaedic Associates or one of the organized health care systems in which Sheboygan Orthopaedic Associates participates.

5. Sheboygan Orthopaedic Associates is permitted or required to use or disclose protected health information without the individual's written consent or authorization in certain circumstances. Examples include, but are not limited to, uses or disclosures required by law; uses and disclosures for public health activities; disclosures for law enforcement purposes; and disclosures reasonably related to a workers' compensation injury.

6. Sheboygan Orthopaedic Associates 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.

7. Sheboygan Orthopaedic Associates will not make any other use or disclosure of a patient's protected health information without the individual's written authorization. Such authorization may be revoked at any time unless the authorization has already been acted on by Sheboygan Orthopaedic Associates. Any revocation must be in writing.

8. An individual is permitted to request that Sheboygan Orthopaedic Associates restrict certain uses or disclosures of their protected health information to carry out treatment, payment, or health care operations. An individual may also request a restriction to a previously executed authorization.

9. Sheboygan Orthopaedic Associates is not required to agree to a requested restriction as described in Paragraph 8. If Sheboygan Orthopaedic Associates does agree, however, it must adhere to the restriction, except when protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to health care providers treating the individual. A restriction also would not apply to those situations outlined in Paragraph 5.

10. Sheboygan Orthopaedic Associates permits individuals, and will accommodate reasonable requests by individuals, to request to receive communications of protected health information from Sheboygan Orthopaedic Associates by alternative means or at alternative locations.

11. An individual has the right to review and obtain a copy of their protected health information, with the exception of information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding. Sheboygan Orthopaedic Associates may charge you a reasonable fee for a copy of your health care record.

12. Individuals have the right to request Sheboygan Orthopaedic Associates amend their protected health information if they believe their health information is incorrect or incomplete. This request must be in writing and must state the reason why the health record should be changed. If Sheboygan Orthopaedic Associates did not create the health information believed to be incorrect, or if Sheboygan Orthopaedic Associates disagrees with the request, Sheboygan Orthopaedic Associates may deny the request.

13. Individuals may request an accounting of disclosures of their protected health information made by Sheboygan Orthopaedic Associates. The accounting will describe the dates of each disclosure, a brief description of the information disclosed and to whom it was disclosed, and the reason for the disclosure. Individuals may receive one accounting per year at no charge, and Sheboygan Orthopaedic Associates may charge a reasonable fee for each subsequent request.

14. lndividuals have the right to receive, upon request, a paper copy of this Notice, even if the individual previously received the Notice electronically.

15. If you believe your privacy rights have been violated, you may file a complaint with Sheboygan Orthopaedic Associates and/or the Secretary of Health and Human Services. To file a complaint with Sheboygan Orthopaedic Associates, please contact the Privacy Officer at the following:

Privacy Officer Sheboygan Orthopaedic Associates
2920 Superior Avenue
Sheboygan, WI 53081
920-458-3791
FAX 920-458-3783

To exercise any of your individual rights with respect to your health information as listed in this notice, please contact the Privacy Officer at Sheboygan Orthopaedic Associates, as listed above, and the appropriate request form will be provided.

16. lt is Sheboygan Orthopaedic Associate's policy that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.

17. This Notice of Privacy Practices is effective as of April 14, 2003.

2920 Superior Avenue, Sheboygan, WI 53081 - 920-458-3791