We are required by applicable federal and state law to maintain the privacy of your medical information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect unless we replace it.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information at the end of this notice.

Treatment: We may use your medical information, without your permission, to treat you. We may disclose your medical information, without your permission, to a physician or other health care provider for your treatment. In an emergency situation involving an immediate threat to your health we may provide your health information to medical staff who are providing treatment to you.

Payment: We may use and disclose your medical information, without your permission, to obtain or provide reimbursement for health care we provide to you. If we bill Medicaid or Medicare for reimbursement, we will submit an electronic claim that includes your name and other personal information.

Health Care Operations: We may use and disclose your medical information for certain of our health care operations. Health care operations include:

• health care quality assessment and improvement activities;

• reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing and credentialing activities;

• conducting or arranging for medical reviews, audits, and legal services

• business planning, development, management, and general administration.

Your Authorization: You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice.

Patient Contact: We may use your medical information to contact you via telephone or mail to discuss the specifics of your personal health and related referrals.

Public Health and Benefit Activities: We may use and disclose your medical information, without your permission, when required by law and in the following situations:

• for public health, including to report communicable disease, immunization records, child abuse, and adult abuse, neglect or domestic violence;

• to avert a serious and imminent threat to health or safety;

• for health care oversight, such as activities of state licensing and peer review authorities;

• to law enforcement officials regarding criminal investigations, in response to court orders, and as required by law and other lawful process. 

You may be able to opt out of use or disclosure of your medical information pursuant to a written request from a government agency, unless the disclosure is required by law.

We may not disclose HIV test results, certain confidential medical information, or mental health treatment records for certain of these purposes without your written permission, unless required by law. Your HIV test results, if any, may be disclosed as set forth in Wisconsin Statutes § 252.15(5)(a). A listing of the persons or circumstances set forth in that statute is available on request.

Contact Information: If you have any questions about your rights under this privacy notice please contact the Privacy Officer.  Specific contact information is located at the end of this notice.

Forms: You may obtain necessary forms to exercise your rights from the Privacy Officer.  Specific contact information is located at the end of this notice

Access: You have the right to examine and to receive a copy of your medical information, with limited exceptions.

Disclosure Accounting: You have the right to a list of instances after April 13, 2003 in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.

Within 60 days of you request, we will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request and never for a disclosure that occurred before April 14, 2003.

Amendment. You have the right to request that we amend your medical information and mental health treatment records. Your request must be in writing, and it must explain why the information should be amended.

We may deny your request only for certain reasons. If we deny your request, we will provide you a written explanation. If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons you want to receive the amendment.

Restriction: You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify. We are not required to agree to your request. If we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law.

Confidential Communication: You have the right to request that we communicate with you about your medical information in confidence by alternative means or to alternative locations that you specify. You must make your request in writing. You should submit your request to the contact at the end of this notice. You may obtain a form from that contact to make your request.

We will accommodate your request if it is reasonable, specifies the alternative means or location for confidential communication. We will not ask you to explain the reason for your request.

Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns or need any forms, please contact the Privacy Officer using the information at the end of this notice.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, in response to a request you made to amend, restrict the use or disclosure of, or communicate in confidence about your medical information, you may complain to us using the contact information at the end of this notice. You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services. You may contact the Office of Civil Rights’ Hotline at 1-800-368-1019.

We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Privacy Officer
Madison Public Health Department
210 Martin Luther King Jr., Blvd., Rm. 507
Madison, WI 53703-3346
(608) 266-4821