When Your Medical Information May Not Be Used

We will not use or disclose your medical information for any reason other than those described on Page 2 of this notice, without your written authorization. You may withdraw this authorization at any time by submitting a completed request form to the address listed in the “To Use Your Rights” section of this document. If you withdraw your authorization, we will no longer be able to use or disclose health information about you for those purposes covered by your written authorization. If authorization is withdrawn, we will be unable to take back any previous disclosures made with your authorization. In the event of an emergency, information may be released without your permission if, medically, it is in your best interest. You will be told as soon as possible after the information is released.

How Your Medical Information is Used or Disclosed Without Written Permission

Your medical information may be used or disclosed for treatment, payment and health care operations without your permission. For examples of these functions, see below. Some services are provided through contracts with other state agencies or private companies. Some or all of your information may be disclosed, without written permission, with the other agency or company so they can do the job we have asked them to do. The other agency or company must also keep your information confidential.Not all types of uses and releases are listed in this notice. Following are some common ways medical information is used or disclosed for treatment, payment and health care operations. For each category we will explain what we mean and give an example.

‍Treatment – Medical information may be used or disclosed to make sure that needed medical treatment and service is received. For example, your medical information may be given to a pharmacist when you need a prescription filled.

‍Payment – Your medical information may be used and disclosed to others to bill and collect payment for the treatment and services you received. Medical information may also be shared with other government programs such as Worker’s Compensation, medicare or private insurance to manage your benefits and payments. For example, we may send a claim form to your insurance company for payment. This claim form includes information identifying you, your diagnosis and treatment.

Health Care Operations – Medical information may be used or disclosed in order to carry out necessary benefit or service related activities. These activities may include quality and cost improvement functions such as conducting or arranging for medical review, quality improvement studies, audit services, management or general administration.

Other ways your medical information may be used or disclosed without written permission include:

‍Informing You – Your information may be used in order to let you know about health and wellbeing services. This may include contacting you for appointment reminders, telling you about treatment alternatives or giving you information about health related benefits or services.

‍Public Health – Information may be reported to a public health authority or other appropriate government authority authorized by law to collect or receive information to help prevent or control disease, injury, disability, infection exposure and child abuse or family violence. The authorities could include local, state or federal governmental agencies. For example, your medical information may be shared if you are exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease.

‍Health Oversight Activities – Information may be shared with other government agencies who provide oversight of the health care system. Examples of this include licensing and inspecting of medical facilities, audits or other proceedings related to oversight of the health care system.

‍Coroners, Medical Examiners or Funeral Directors – Your medical information may be released to a medical examiner, coroner or funeral director as needed to carry out duties unauthorized by law. For example, this may be necessary to identify a deceased person.

‍For Organ Donations – If you are an organ donor, information may be given to the organization that finds or transplants organs for the purpose of an organ transplantation or donation.

‍Worker’s Compensation – Your information may be disclosed to comply with Worker’s Compensation or similar laws.Public Safety – Your information may be disclosed to prevent or lessen a serious threat to your health or safety, to another person or the general public.

‍Specialized Government Functions – Your information may be used or disclosed to the government for specialized government functions. For example, your information may be disclosed to the appropriate military authorities if you are or have been a member of the U.S. armed forces.

‍Law Enforcement – Your information may be disclosed to fulfill a requirement by law or law enforcement agencies. As an example, medical information may be used to identify or locate a missing person.

‍Court or Other Hearings – Your information may be disclosed to comply with a court order.Required by Law – In addition to the ways listed above in which your medical information may be disclosed, Kagen Allergy Clinic may share your information when required by law.

Your Medical Information Policy Rights

You have the right to:
See or Copy Your Medical Information – To see or copy enrollment, claim or other records used to make decisions about your health plan services, send in a completed request form to the address listed in the “To Use Your Rights” section of this document. Kagen Allergy Clinic will not include information prepared for legal actions or proceedings. A fee may be charged to cover the processing cost of your request.

‍Correct Information You Believe to be Incorrect or Incomplete – To ask for a correction to enrollment, claim or other records used to make decisions about your health plan services, send in a completed request form to the address listed in the “To Use Your Rights” section of this document. Your request will be reviewed. If the change is not allowed, you will be told in writing why and how you can disagree.

‍Request a List of Who Was Given Your Information and Why – Such a list will not include information used for payment of your treatment, our health care operations, any information already provided on a previous list, national security, law enforcement/corrections, or certain health oversight activities. Information given to you will include the release date, the name of the person or organization, a brief description, and the reason for the disclosure. The list will not include dates before April 14, 2003, or go back more than six years. Kagen Allergy Clinic will provide one list per year free of charge. There may be a charge for additional lists. To obtain such a list, send a completed request form to the address listed in the “To Use Your Rights” section of this document.

‍Request Restrictions on using or Sharing Your Medical Information for Treatment, Payment or Health Care Operations – You have the right to request restrictions on how your information is used or disclosed. Kagen Allergy Clinic is not required to agree to your requested restrictions. After sending a completed request form to the address listed below, your request will be evaluated. We will let you know if we can comply with the restriction or not.

‍Request that You be Informed about Your Health in a Way or at a Location that will help keep your Information Private. – You have a right to request how and where Kagen Allergy Clinic contacts you about your medical information. After sending a completed request form to the address listed in the “To Use Your Rights” section of this document, your request will be evaluated and Kagen Allergy Clinic will let you know if it can be done.

‍Receive a Paper Copy of this Notice – You have the right to ask for and receive a paper copy of this notice.

TO USE YOUR RIGHTS
To use any of these rights or to obtain a copy of the correct privacy request form for inspecting, copying, amending, making restrictions, or obtaining an accounting of your health information, call Kagen Allergy Clinic for a request form at 920-739-9100. Send your completed privacy request form to Kagen Allergy Clinic, Privacy Officer, 100 W. Lawrence Street, Appleton, Wisconsin 54911.

‍CHANGES TO THIS NOTICE
This notice may be changed or amended at any time. The changes are effective for all medical information including what is on file. A new notice will be posted.

‍FOR MORE INFORMATION
If you have questions about any part of this notice or would like additional information about our privacy practices, please write to Kagen Allergy Clinic, Privacy Officer, 100 W. Lawrence Street, Appleton, Wisconsin 54911.

‍COMPLAINTS
To obtain a complaint form, call Kagen Allergy Clinic at 920-739-9100. Please send written complaints about this notice, about how Kagen Allergy Clinic handled your medical information, or if you believe your privacy rights have been violated to Kagen Allergy Clinic, Privacy Officer, 100 W. Lawrence Street, Appleton, Wisconsin 54911.You may also file a complaint directly with the Secretary of the U.S. Department of Health and Human Services by writing to the Privacy Officer, Office of Civil Rights, Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201. For additional information call 866-627-7748.

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