Privacy Policy

This Notice of Privacy Practices (Notice) applies to the privacy practices of Lake Country Pediatrics, S.C.


Lake Country Pediatrics, S.C. must keep your health information private. We are required to give you this Notice to tell you about our legal duties, the practices we follow to keep your health information private, and your rights concerning your health information. When we release your health information, we must release only the information needed for the specific purpose.

We will follow the privacy practices in this Notice.


Without your written permission, we can use and release your health information for:

1. Treatment. We may use or release your health information to a physician or other health care provider in order to provide treatment to you.

For example, a doctor may use the information in your medical record to decide what treatment, such as a drug or surgery, best meets your health needs. The treatment chosen will be written in your medical record, so that other health care professionals can make the best decisions for your care.

We may also use your health information to:

  • Schedule a test such as a lab or x-ray
  • Call a prescription to your pharmacy
  • Continue your care


2. Payment. We may use and disclose your health information to obtain payment for services we provide to you.

For example, we must send a bill that gives your name, your diagnosis, and the care you received to your insurance company. We will give this health information to help get payment for your medical bills.

We may disclose your health information to another health provider or entity subject to the federal Privacy Rules so they can obtain payment.

We may need your written permission to disclose information taken from your mental health treatment records or HIV test results for payment purposes.


3. Health Care Operations. We may use and disclose your health information in connection with our health care operations.

For example, your diagnosis, treatment, and results may help improve the quality or cost of care we give our patients. These quality and cost improvement activities may include:

  • Reviewing the performance of your doctors, nurses and other health care professionals.
  • Looking at the success of your treatment and comparing the success to other patients.
  • Calling a patient and leaving a reminder message for a scheduled appointment.
  • Health care review or accreditation reviewers.

Other health care operations for which we can use or disclose your health information include:

  • Conducting training programs, accreditation, certification, licensing or credentialing activities.
  • Medical review, legal services, and auditing, including fraud and abuse detection and compliance.

We may use information found in your medical record, such as your name, address, and phone number to contact you for our special events

We may disclose your health information to another entity, which has a relationship with you and is subject to the federal privacy rules, for their health care operations relating to quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, or detecting or preventing health care fraud and abuse.

We may need your written permission to disclose health information or information taken from your mental health treatment records or HIV test results for health care operations.


4. As required by law. We may use or disclose your health information as required by law to the police, court officials or government agencies.

For example, we may report:

  • Abuse
  • Neglect
  • Certain physical injuries


5. For public health activities. We may need to report your health information to help prevent or control disease, injury or disability. This may include information for:

  • Disease, injury, and vital statistic reporting
  • Child abuse reporting
  • Food and Drug Administration
  • Poison control


6. For health oversight activities. We may give your health information to health oversight agencies, including agencies who monitor or regulate hospitals, clinics, nursing homes, or other health care providers to be certain you are given the correct and proper care


7. For activities related to death. We may reveal your health information to coroners and medical examiners. Such as:

  • Identifying the body
  • Finding cause of death

8. For organ, eye or tissue donation. We may give your health information to people who obtain, store or transplant organs, eyes or tissue of people who have died.


9. To avoid a serious threat to health or safety. We may release some of your medical record to people in authority if we think that it will prevent or lessen a serious or imminent danger to yourself or the safety and health of other people.


I 0. For military or national security purposes. We may release your health information to military and federal officials for lawful national security or intelligence activities.


11. For workers' compensation. We may share your health information as allowed by workers' compensation laws or other similar programs such as Family Medical Leave Act and disability claims. These programs may provide benefits for work-related injuries or illness.


12. Law enforcement and correctional facilities. We may disclose your health information to law enforcement officials pursuant to subpoenas under a court order, and signed by a judge, or other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person. We may disclose your health information to correctional institutions or law enforcement personnel for certain purposes if you are an inmate or are in lawful custody.


13. To those involved with your care or payment of your care. If family members or close friends are helping care for you or helping you pay your medical bills, we may give health information about you to those people to the extent necessary for them to help with your care or payment for your care. The information given may include your name. We must give you enough information so you can decide if you want other people involved with your care to have information from your medical records. If you are unable to agree or object to such disclosure we may information as necessary to determine that it is in your best interest based on professional judgment.


14. Disaster Situations. We may release your medical record to people who handle disasters so people who care for you can have needed information. We must inform you of these releases and honor any written restrictions you may impose, unless so doing would restrict our ability to respond to an emergency.


15. HlV Test Results. 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.


With your written permission:

We may use your health information to disclose it to anyone for any purpose. If the reason we share health information is not listed above, we must first get your written permission. For example, we must get your written permission to share psychotherapy notes unless we need those notes to treat you or if we are required by law. If you sign a permission form, you may withdraw your permission at any time, as long as you notify us in writing. If you wish to withdraw your permission, please send your written request to the medical record department at the hospital, medical center or place where you were treated. Your revocation will not affect any use or disclosures whole your permission was in effect.

Your Health Information Rights:

If you wish to use any of the following rights with respect to your health information, please contact the medical record department at the hospital, medical center or place where you were treated. You have the right to:

1. Inspect and copy your health information. With exceptions, you have the right to look at and receive a copy of your medical record. You may need to pay a fee if you want a copy of your medical record.

2. Request to challenge or correct your health information. If you believe your health information is not correct, you may ask us to change/correct the information. You will be asked to make your request in writing and you will be asked to give a reason as to why your health information should be changed. We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

3. Request restrictions on certain uses and disclosures. You may limit how your health information is used. You may ask us to limit the information given to family and friends or those who help in emergencies. We are not required to agree to these restrictions, but if we do, we will abide by our agreement (except in an emergency). All requests for restriction must be in writing.

4. As applicable, receive confidential communication of health information. You have the right to ask that we share your health information with you in different ways or places. For example, you may ask to learn about your health status in a private area or by a letter sent to a private address. We will meet reasonable requests that specify the alternative means or location and provide a satisfactory explanation how payments will be handled under the alternative means or location you request. If requesting confidential communication the request must be in writing.

5. Obtain a paper copy of this Notice. A paper copy of this Notice will be given to you even if you have received this Notice on our web site or by electronic mail (e-mail). Even if you received a copy of the Notice before, you may still be asked to sign that you have received the Notice.

6. Complaint Filing. If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer or with the Federal Department of Health and Human Services. We will not retaliate against you for filing such a complaint. You may submit your request in writing to:

  • File a complaint or to comment on our privacy practices
  • Amend your health information
  • Access your health information
  • Request a restriction on your confidential communication of your health information
  • Receive a listing of disclosures of your health information

All requests in writing should be sent to the medical record department at the hospital, medical center or place where you were treated.


This Notice of Privacy Practice is Effective April 14, 2003.