HEALTH CARE PROVIDER

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Effective Date:  4/14/03

Introduction:  In order to provide health care services through its Health and Fire Rescue Departments, the City of De Pere must obtain and maintain protected health information from you, the client/patient.  This Notice of Privacy Practices describes the types of information that is collected and your rights with respect to that information.

"Protected health information"  (PHI) means information that is individually identifiable as to the current client/patient or applicant for health care treatment, payment or operations.  This information is obtained from applications for health care coverage, requests for emergency services, claims for payment filed by health care providers, and your medical records.  PHI may also be obtained over the telephone from requestors of emergency services.  Other sources of protected health information include group health plan administrators, employers, and business partners such as third-party administrators, medicare and other entities engaged in obtaining health care information.

"PHI" includes the following:

*  Your health history, including communicable disease reports

*  Your medical records, including medical charts

*  Your name, address, and date of birth

*  Your marital status

*  Gender

*  Social Security number

*  Information regarding your dependents

*  Other similar information that relates to past, present or future medical care

Uses and disclosures for treatment: Your PHI may be disclosed to health care providers including doctors, nurses, laboratory technicians, medical students and other health care personnel involved in your treatment.  The Health Department may, in addition, disclose your protected health information to other public health agencies.  Additionally, your protected health information will be disclosed in response to legal requirements.

Uses and disclosures for payment: Your PHI may be used or disclosed to individuals involved in payment for your treatment in order to determine eligibility for payment and eligibility for plan benefits.  Your protected health information may be shared with persons involved in utilization review, to assist in subrogation of health care claims, or other adjudication procedures.

Uses and disclosures required by law:  The City will disclose your PHI as required by law but only to the extent necessary to comply with that legal requirement.

The City may also share this information with business partners for purposes of utilization reviews, appropriateness of care reviews, consultation with outside health care providers, consultants, and attorneys.  The City requires its business partners to sign a contract specifying their compliance with these privacy policies.

In order to ensure the privacy of your protected health information, the City has developed privacy policies and procedures.  Procedures are based on appropriate administrative, technical and physical safeguards necessary to maintain confidentiality of your protected health information. 

Such information is limited to those individuals that have a legitimate business need for that information.  This protection extends to use of your protected health information by City business partners.

Non-routine disclosures of personal health information:

In all other circumstances, the City will ask for your authorization to use or disclose your protected health information.  The City will use or disclose information in these circumstances only according to your authorization and will only use or disclose the minimum amount of information necessary to perform the non-routine function.  Examples may be to release your personal health information to your employer for workers' compensation purposes, or for automobile insurance claims.  In most cases, authorization to disclose must be made by the person to which the protected health information pertains.  In some circumstances however, authorization to disclose may be obtained from a person representing your interests (such as in the case where you may be too incapacitated to make an informal authorization) or in emergency situations where your authorization would be impractical to obtain.

Non-routine disclosures may include:

*  The health plan sponsor for payment or other claims purposes

*  Organ donation and tissue transplant if you are an organ or tissue donor

*  The military if you are a member of the armed services

*  Workers' compensation carriers

*  Legal representatives in response to a court order or other legal proceedings

*  National security and intelligence agencies as authorized by law

*  Correctional institutions if you are an inmate

Your Rights:

You have the right to review your protected health information maintained by the City of De Pere and to obtain a copy of such information.  A reasonable fee may be charged for copies of your health information records. 

You also have the right to request changes to your protected health information or to register a complaint with the City of De Pere Privacy Officer.  Requests for changes must be made in writing and must include a reason for the requested change.  You have a right to a timely written denial of those requested changes.

You have a right to request an accounting of disclosures of your protected health information made by the City of De Pere.  This request must be made in writing and may not be for a period longer than six years.

You have a right to request a restriction on the protected health information that may be disclosed.  The City of De Pere is not required to agree to this request.

You have the right to request that communications regarding your protected health information from the City of De Pere be made at a certain time or location.  This request must be in writing.  The City of De Pere will accommodate reasonable requests.

Changes to Privacy Practices:

If the City of De Pere changes its privacy policies and procedures, an updated Notice of Privacy Practices will be provided upon further treatment by the City of De Pere. 

Up-to-date privacy notices are maintained on the City of De Pere web site at www-de-pere.org

City of De Pere Privacy Officer:

The Privacy Officer for the City of DePere is:

Human Resources Director
335 S. Broadway
DePere, WI  54115
Phone:  920-339-4045
Fax:  920-339-4049
E-mail: deperehr@mail.de-pere.org