This notice describes how Fox Valley Hematology & Oncology, S.C. may use and disclose your healthcare information and how you can obtain access to this information. Please review it carefully.

Fox Valley Hematology & Oncology, S.C. 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 Hematology & Oncology, S.C. or received by Fox Valley Hematology & Oncology, S.C. from other health care 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 Hematology & Oncology, S.C. 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.

In order to facilitate access to health information that may be needed for your care, Fox Valley Hematology & Oncology, S.C. stores health information about patients in a joint electronic medical record with other health care providers who participate in the arrangement. Each participant in this arrangement has implemented appropriate policies and procedures for the appropriate access of health information stored in the shared electronic medical record. You may contact the Privacy Officer for a list of healthcare providers who participate in the joint electronic medical record.

Fox Valley Hematology & Oncology, S.C. 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 Hematology & Oncology, S.C. may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment activities, and healthcare operations.

Treatment may include:

  • 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 other providers for treatment;
  • Referrals to nursing homes, foster care homes, or home health agencies.

For example, Fox Valley Hematology & Oncology, S.C. may determine that you require the services of a specialist.

In referring you to another doctor, Fox Valley Hematology & Oncology, S.C. may share or transfer your healthcare information to that doctor.

This Notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F.R. 164.520, and applicable Wisconsin healthcare privacy laws.

Payment activities may include:

  • Activities undertaken by Fox Valley Hematology & Oncology, S.C. 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;
  • ollection activities to obtain payment for services provided to you;
  • Reviewing health care 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.

For example, Fox Valley Hematology & Oncology, S.C. 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 health care 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 Hematology & Oncology, S.C. 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.

There are special protections under the law for certain types of health information, which include HIV test results and information relating to registration and treatment for mental illness, developmental disabilities, alcoholism, or drug dependence. Fox Valley Hematology & Oncology, S.C. may need your written
authorization to release these types of information, even if the release is for purposes of treatment, payment activities, or healthcare operations. When a more protective law applies, Fox Valley Hematology & Oncology, S.C. will follow the requirements of that law and obtain your written authorization before releasing this information.

Fox Valley Hematology & Oncology, S.C. may contact you, by telephone, mail, or by electronic communication 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 parent, 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 Hematology & Oncology, S.C. 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.

Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on your premises.

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 to report positive HIV test results to the state epidemiologist. We may also disclose HIV test results to other providers or persons when there has been or will be risk of exposure. We may report to the state epidemiologist the name of any person known to have been significantly exposed to a patient who tests positive for HIV. We are required by law to report suspected child abuse and neglect and suspected abuse of an unborn child, but cannot disclose HIV test results in connection with the reporting or prosecution of alleged abuse or neglect. We may release healthcare records, including treatment records and HIV test results, to the Food and Drug Administration when required by federal law. We may disclose healthcare records, except for HIV test results, 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, including treatment records, in response to a written request by any federal or state government agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification. HIV test results may not be released to federal or state governmental agencies, without written permission, except to the state epidemiologist for surveillance, investigation, or to control communicable diseases.

For judicial and administrative proceedings.

Patient healthcare records, including treatment records and HIV test results, may be disclosed pursuant to a lawful court order. A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records except for HIV test results.

For activities related to death.

We may disclose patient healthcare records, except for treatment records, to a coroner or medical examiner for the purpose of completing a medical certificate or investigating a death. HIV test results may be disclosed under certain circumstances.

For organ, eye, or tissue donation.

Fox Valley Hematology & Oncology, S.C. may disclose your health information to entities involved in obtaining, banking, or transplanting organs, eyes, or tissue for donation or transplantation purposes.

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, including treatment records and HIV test results, may be disclosed where disclosure is necessary to protect the patient or community from imminent and substantial danger.

For specialized government functions.

Fox Valley Hematology & Oncology, S.C. may use or disclose your health information for specialized government functions, such as military and veterans’ activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, and correctional institutions, and other law enforcement custodial situations.

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 Hematology & Oncology, S.C. will not make any other use or disclosure of your protected health information without your written authorization. We must obtain your written authorization for the following: (1) most uses of disclosures of psychotherapy notes, (2) uses or disclosures of your health information for outside marketing purposes, and (3) disclosure of your health information in exchange for direct or indirect remuneration to Fox Valley Hematology & Oncology, S.C. You may revoke any authorization you give at any time, except to the extent that Fox Valley Hematology & Oncology, S.C. 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 Hematology & Oncology, S.C. 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, except that we must agree to your request to restrict disclosure of your health information to your health plan about services or items that were paid for in full by you. In those situations where we agree to a requested restriction, 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. You have the right to request that your healthcare records be provided in an electronic form or format. If the form or format requested is not readily producible, then we will work with you to provide your health information in a reasonable electronic form or format. Fox Valley Hematology & Oncology, S.C. 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 the cost of copying, mailing, or for other supplies.

You may request that Fox Valley Hematology & Oncology, S.C. send protected health information, including billing information, to you by alternative means or to alternative locations. You may also request that Fox Valley Hematology & Oncology, S.C. 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 Hematology & Oncology, S.C. 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 Hematology & Oncology, S.C. for the six years prior to the date of the request, beginning with disclosures made after April 14, 2003. We are not required, however, to record disclosures made pursuant to a signed consent or authorization, disclosures made for treatment, payment or healthcare operations, information that is part of a limited data set, disclosures made to the patient, or disclosures made in situations where the use or disclosure is permitted or required by law.

You have the right to be notified of any breaches of your unsecured health information.

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 Hematology & Oncology, S.C. and/or the Secretary of Health and Human Services if they believe their privacy rights have been violated. The file a complaint with Fox Valley Hematology & Oncology, S.C. or for further information, please contact the Privacy Officer at the following:

Privacy Officer

Fox Valley Hematology & Oncology, S.C.

3925 N. Gateway Dr.

Appleton, Wl 54913 920-749-1171

It is the policy of Fox Valley Hematology & Oncology, S.C. 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.

This notice of Privacy Practices is effective April 14, 2014.

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