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HIPAA Privacy Policy

Notice of Privacy Practices

This notice describes how Fox Valley Plastic Surgery, serving Milwaukee, the Fox Cities, Green Bay, and beyond, may use and disclose your healthcare information and how you can obtain access to this information. Please review it carefully.

Fox Valley Plastic Surgery in Wisconsin is required by law to maintain the privacy of your protected health information. This information consists of all records related to your health, including demographic information, either created by Fox Valley Plastic Surgery or received by Fox Valley Plastic Surgery from other healthcare providers.

We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. Fox Valley Plastic Surgery will abide by the terms of this Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information.

Fox Valley Plastic Surgery reserves the right to change the terms of this Notice and to make any new provisions effective for all protected health information that we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time.

Uses and Disclosures of Your Protected Health Information Not Requiring Your Consent

Fox Valley Plastic Surgery may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment and healthcare operations.

Treatment may include:

• Providing, coordinating, or managing healthcare and related services by one or more healthcare providers;
• Consultations between healthcare providers concerning a patient;
• Referrals to other providers for treatment;
• Referrals to nursing homes, foster care homes, or home health agencies.

For example, Fox Valley Plastic Surgery may determine that you require the services of a specialist. In referring you to another doctor, Fox Valley Plastic Surgery may share or transfer your healthcare information to that doctor.

Payment activities may include:

Activities undertaken by Fox Valley Plastic Surgery to obtain reimbursement for services provided to you;

• Determining your eligibility for benefits or health insurance coverage;
• Managing claims and contacting your insurance company regarding payment;
• Collection activities to obtain payment for services provided to you;
• Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under your health plan, appropriateness of care, or justification of charges;
• Obtaining pre-certification and pre-authorization of services to be provided to you.

Fox example, Fox Valley Plastic Surgery will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided to you.

Healthcare operations may include:

• Contacting healthcare providers and patients with information about treatment alternatives;
• Conducting quality assessment and improvement activities;
• Conducting outcomes evaluation and development of clinical guidelines;
• Protocol development, case management, or care coordination;
• Conducting or arranging for medical review, legal services, and auditing functions.

For example, Fox Valley Plastic Surgery may use your diagnosis, treatment, and outcome information to measure the quality of the services that we provide, or assess the effectiveness of your treatment when compared to patients in similar situations.

Fox Valley Plastic Surgery may contact you, by telephone or mail, to provide appointment reminders. You must notify us if you do not wish to receive appointment reminders.

We may not disclose your protected health information to family members or friends who may be involved with your treatment or care without your written permission. Health information may be released without written permission to a patient, guardian, or legal custodian of a child; the guardian of an incompetent adult; the healthcare agent designated in an incapacitated patient’s healthcare power of attorney; or the personal representative or spouse of a deceased patient.

There are additional situations when Fox Valley Plastic Surgery is permitted or required to use or disclose your protected health information without your consent or authorization.

Examples include the following:

• As permitted or required by law. In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries. We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe that the wound occurred as a result of a crime.
• For public health activities. We may release healthcare records, with the exception of treatment records, to certain government agencies or public health authority authorized by law, upon receipt of written request from that agency. We are required by law to report suspected child abuse and neglect and suspected abuse of an unborn child. We may release healthcare records, to the Food and Drug Administration when required by federal law. We may disclose healthcare records for the purpose of reporting elder abuse or neglect, provided the subject of the abuse or neglect agrees, or if necessary to prevent serious harm. Records may be released for the reporting of domestic violence if necessary to protect the patient or community from imminent and substantial danger.
• For health oversight activities. We may disclose healthcare records in response to written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification.
• Judicial and Administrative Proceedings. Patient healthcare records may be disclosed pursuant to a lawsuit court order. A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records.
• For activities related to death. We may disclose patient healthcare records to a coroner or medical examiner for purpose of completing a medical certificate or investigating a death.
• For research. Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.
• To avoid a serious threat to health or safety. We may report a patient’s name and other relevant data to the Department of Transportation if it is believed the patient’s vision or physical or mental condition affects the patient’s ability to exercise reasonable or ordinary control over a motor vehicle. Healthcare information may be disclosed where disclosure is necessary to protect the patient or community from imminent and substantial danger.
• For Workers Compensation. We may disclose your health information to the extent such records are reasonably related to any injury for which Workers Compensation is claimed.

Fox Valley Plastic Surgery will not make any other use or disclosure of your protected health information without your written authorization. You may revoke such authorization at any time, except to the extent that Fox Valley Plastic Surgery has taken action in reliance thereon. Any revocation must be in writing.

Your Rights Regarding Your Protected Health Information

You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by Fox Valley Plastic Surgery to carry out treatment, payment, or healthcare operations. You must request such a restriction in writing. We are not required to agree to your request, but if we do agree, we must adhere to the restriction, except when your protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to healthcare providers treating you. Also, a restriction would not apply when we are required by law to disclose certain healthcare information.

You have the right to review and/or obtain a copy of your healthcare records, with the exception of psychotherapy notes, or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding. Fox Valley Plastic Surgery may deny an access under other circumstances, in which case you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records.

You may request that Fox Valley Plastic Surgery send protected health information, including billing information, to you by alternative means or to alternative locations. You also request that Fox Valley Plastic Surgery not send information to a particular address or location or contact you at a specific location, perhaps your place of employment. This request must be submitted in writing. We will accommodate reasonable requests by you.

You have the right to request that Fox Valley Plastic Surgery amend portions of your healthcare records, as long as such information is maintained by us. You must submit this request in writing, and under certain circumstances the request may be denied.

You may request to receive an accounting of the disclosures of your protected health information made by Fox Valley Plastic Surgery for the six years prior to the date of the request, beginning with disclosures made after April 14th, 2003. We are not required, however, to record disclosures we make pursuant to signed consent or authorization.

You may request and receive a paper copy of this Notice, if you had previously received or agreed to receive the Notice electronically.

Any person or patient may file a complaint with Fox Valley Plastic Surgery and/or the Secretary of Health and Human Services if he or she believes their privacy rights have been violated. To file a complaint with Fox Valley Plastic Surgery, please contact the Privacy Officer at the following:

Dianne Thompson, Administrator
Fox Valley Plastic Surgery SC
2400 Witzel Ave., Suite A
Oshkosh, WI 54904
920-233-1540

It is the policy of Fox Valley Plastic Surgery that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance or violation of the privacy standards.