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Notice of Privacy Practices

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Notice of Privacy Practices Regarding Health Information

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.


 Sheboygan County Health and Human Services Department recognizes a patient's right to receive adequate notice of the uses and disclosures of Protected Health Information that may be made by the Department, and of the patient's rights and the Department's legal duties with respect to Protected Health Information.


The Department uses health information from your medical records to provide treatment to you, to arrange for payment, and for health care operations:
1.  TREATMENT:  The Department may share your medical information with a physician or other health care provider.  Any treatment would be noted in your records for any other doctors, nurses, caseworkers, or therapists to see.  For example, case managers involved in your care will need information about your diagnosis to develop a treatment plan.  If you are being treated for a Chapter 51 service (Mental Illness, Developmental Disability, or AODA), only internal disclosure is permitted without authorization.
2.  PAYMENT:  The Department may submit your health information to Medical Assistance, the State of Wisconsin, or other third party payors for reimbursement.  When it does this, it will share the least amount of information so that payment can be made.  Usually, this involves identifying you, your diagnosis, and the treatment provided.  Chapter 51 services and HIV treatment require your authorization.
3.  HEALTH CARE OPERATIONS:  The Department may look at your file to review our operations.  These quality and cost-improvement activities may include evaluating the performance of other doctors, nurses, caseworkers, therapists, and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to similarly situated patients.
4.  REMINDERS AND INFORMATION SHARING:  Your health information may be reviewed if it is time for us to reestablish your eligibility, to conduct reassessments for case review, or for a routine visit.  We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

The law allows the Department to share your protected health information without your authorization:
1.  As required or permitted by law:  If any aspect of your medical information becomes the interest of a legal proceeding, court, or administrative action.  For example, we may have to report abuse, neglect, or certain physical injuries, or respond to a court order.
2.  For public health reasons:  As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
3.  Health oversight activities:  Information may be shared with other government agencies to 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.
4.  Death Records:  Information about death is recorded and documented by various authorities, i.e., the Register of Deeds, Coroner, and Medical Examiner.
5.  Organ Donation:  In the case of organ donation, information must be shared to get a match.
6.  Research:  Under certain circumstances, and only after a special approval process, to help conduct research.
7.  Health and Safety Threat:  Information may be disclosed to prevent or lessen a serious threat to your health or safety, to another person, or the general public.
8.  Specialized Government Functions/Law Enforcement:  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.  Information may be disclosed to fulfill a requirement by law or law enforcement agencies.  As an example, information may be used if you are in custody of law enforcement or an inmate in a correctional institution.
9.  Worker's Compensation:  Health information may be disclosed according to the law if it involves worker's compensation laws and benefits or similar programs for work related injury or illness.
10.  Disaster Relief:  Information may be disclosed to organizations assisting in disaster relief effort so that your family can be notified about your condition and location.
11.  To those involved in your care or payment for your care:  Family members and other legally responsible parties may be given information regarding your care and treatment.
12.  Business Associates:  There are some services provided in our organization through contracts with business associates or service providers.  When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do.  To protect your health information, however, we require the business associate to appropriately safeguard your information.
13.  Statutory Exceptions:  Wisconsin Statutes 51.30 and 252.
Wisconsin Statutes 51.30 and 252 limit the release of health information without your consent.

The Department may use or disclose your personal health information only with your written permission, except as described in the previous sections.  If you gave us permission, you may withdraw such permission at any time by notifying us in writing, except if we have already taken action based on your permission.

Health Information:  is defined as any information, whether oral or recorded in any form or medium, that - (1) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (2) relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.


ACCESS:  You have a right to inspect and obtain a copy of your health information, including billing records.  We may charge you a reasonable fee for copies.  This does not apply to psychotherapy notes or information gathered for judicial proceedings, for example.
DISCLOSURES:  The Department must keep a record or who your information was disclosed to without your written consent after April 14, 2003.  You have a right to see the disclosure record.  You may request this information in writing from the Sheboygan County Health and Human Services Department Privacy Officer.  The written request must specify the time period of the accounting.  The first list you request within a 12-month period will be free.  For additional lists, we may charge you the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request before the costs are incurred.
RECEIVE A PAPER COPY OF THIS NOTICE:  Upon your request, you may, at any time, receive a paper copy of this notice.  This notice is available at all reception areas in the Department's main building and Annex locations.  A current copy may also be obtained from the Sheboygan County Website.  English     Spanish     Hmong
RESTRICTION:  You have the right to request additional restrictions.  The Department does not have to agree to the request.  However, if it does, the agreement must be in writing.
CONFIDENTIAL COMMUNICATIONS:  You have the right to request that we make arrangements with you to communicate with you in a different manner than usual.  This request must be in writing and must state that if given to you in the usual manner, this information could endanger you in some way.  If your request is reasonable, specifies an alternate manner, and satisfies how payments will be made, it must be accommodated in accordance with the law.
AMENDMENT:  You do not have the right to change your medical information.  You have the right to request that we clarify your medical information by adding information to your records.  Your request must be in writing, and it must explain why the information should be amended.  The Department has the right to deny your request.  The denial will be in writing.  You may respond with a statement in writing as to why you would disagree with the decision, which will be added to the records.  If we agree to amend the records as requested, we may also make reasonable effort to inform others, including specific parties named by the consumer, of the changes.
COMPLAINT PROCESS:  Sheboygan County Health and Human Services Department has a documented complaint process regarding the user and/or disclosure of protected health information.  If you wish to file a complaint, you may call, write, or present in person to the Privacy Officer at:

Sheboygan County Health and Human Services Department
1011 North 8th Street
Sheboygan, WI  53081
(920) 459-6400


You may file a complaint with the Secretary of the United States Department of Health and Human Services.  We will not retaliate against you for filing such a complaint.

Sheboygan County reserves the right to change this notice at any time.  In the event of a change, Sheboygan County will provide a copy of the revised notice to you upon request.

EFFECTIVE DATE:  This notice is effective April 14, 2003
Version #1:  First printed April 2003.

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