NOTICE OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In
conducting our business, we will create records regarding you and the treatment and services we provide to you. We are
required by law to maintain the confidentiality of health information that identifies you. We also are required by law to
provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your
IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the
We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your IIHI
- Your privacy rights in your IIHI
- Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We
reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will
be effective for all of your records that our practice has created or maintained in the past, and for any of your
records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our
offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Dr. Brian Erdmann, Anovia Health at firstname.lastname@example.org or (920) 310-8920.
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI)
IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your IIHI.
1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests
(such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in
order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for
you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use
or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your
IIHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.
2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items
you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits
(and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine
if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from
third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you
directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their
billing and collection efforts.
3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As examples of the
ways in which we may use and disclose your information for our operations, our practice may use your IIHI to
evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for
our practice. We may disclose your IIHI to other health care providers and entities to assist in their health care
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential treatment options or
6. Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you of health-related
benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family member that is
involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a
babysitter take a child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have
access to this child’s medical information.
8. Disclosures Required by Law. Our practice will use and disclose your IIHI when we are required to do so by
federal, state or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to
collect information for purposes such as:
- maintaining vital records, such as births and deaths
- reporting child abuse or neglect
- preventing or controlling disease, injury or disability
- notifying a person regarding potential exposure to a communicable disease
- notifying a person regarding a potential risk for spreading or contracting a disease or condition
- reporting reactions to drugs or problems with products or devices
- notifying individuals if a product or device they may be using has been recalled
- notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
- Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities
authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure
and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the
government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or
administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in
response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if
we have made an effort to inform you of the request or to obtain a court or administrative order protecting the
information the party has requested.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
- Concerning a death we believe has resulted from criminal conduct
- Regarding criminal conduct at our offices
- In response to a warrant, summons, court order, subpoena or similar legal process
- To identify/locate a suspect, material witness, fugitive or missing person
- In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or
location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual
or to identify the cause of death. If necessary, we also may release information in order for funeral directors to
perform their jobs.
6. Organ and Tissue Donation. Our practice may release your IIHI to organizations that handle organ, eye or tissue
procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and
transplantation if you are an organ donor.
7. Research. Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. We
will obtain your written authorization to use your IIHI for research purposes except when an Internal Review Board or
Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure
involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the
identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity
consistent with the research (unless there is a health or research justification for retaining the identifiers or such
retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or
disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for
other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be
conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of
8. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to reduce or
prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under
these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
9. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose your IIHI to federal officials for intelligence and national security
activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other
officials or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an
inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for
the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to
protect your health and safety or the health and safety of other individuals.
12. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI that we maintain about you:
1. Confidential Communications. You have the right to request that our practice communicate with you about your
health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you
at home, rather than work. In order to request a type of confidential communication, you must make a written request
to Dr. Brian Erdmann at Anovia Health, Box 230 1794 Allouez Ave Suite C, Green Bay, WI 54311-6281. In the letter,
please specify the requested method of contact, or the location where you wish to be contacted. Our practice will
accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for
treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure
of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members
and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement
except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to
request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Dr. Brian
Erdmann at Anovia Health, Box 230 1794 Allouez Ave Suite C, Green Bay, WI 54311-6281 . Your request must
describe in a clear and concise fashion:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure or both; and
(c) To whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make
decisions about you, including patient medical records and billing records, but not including psychotherapy notes.
You must submit your request in writing to Dr. Brian Erdmann at Anovia Health, Box 230 1794 Allouez Ave Suite C,
Green Bay, WI 54311-6281 in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for
the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to
inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another
licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you
may request an amendment for as long as the information is kept by or for our practice. To request an amendment,
your request must be made in writing and submitted to Dr. Brian Erdmann at Anovia Health, Box 230 1794 Allouez
Ave Suite C, Green Bay, WI 54311-6281. You must provide us with a reason that supports your request for
amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your
request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be
permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the
information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An
“accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-
treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our practice
is not required to be documented. For example, the doctor sharing information with the nurse; or the billing
department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you
must submit your request in writing to Dr. Brian Erdmann at Anovia Health, Box 230 1794 Allouez Ave Suite C,
Green Bay, WI 54311-6281. All requests for an “accounting of disclosures” must state a time period, which may not
be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list
you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the
same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may
withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices.
You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Dr. Brian
Erdmann at Anovia Health, Box 230 1794 Allouez Ave Suite C, Green Bay, WI 54311-6281,
email@example.com or (920) 310-8920.
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our
practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice,
contact Dr. Brian Erdmann at Anovia Health, Box 230 1794 Allouez Ave Suite C, Green Bay, WI 54311-6281. All
complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written
authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any
authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing.
After you revoke your authorization, we will no longer use or disclose your IIHI for the purposes described in the
authorization. Please note, we are required to retain records of your care.