THIS NOTICE DESCRIBES

1. HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
2. HOW WE ASSURE OUR SYSTEM IS FAIR AND WORKS TO MEET YOUR NEEDS.
3. A WAY FOR YOU TO ADDRESS PROBLEMS
4. YOUR ACTIVE ROLL AS A CLIENT IN YOUR HEALTH.

PLEASE REVIEW IT CAREFULLY

 

Purpose: Footprints in Time Midwifery Services (FITMS) and its faculty, students, residents, employees, and non-employees follow the privacy practices and patient rights described in this Notice. FITMS maintains your health information in records that are kept in a confidential manner, as required by law. FITMS must use and disclose or share your health information as necessary for treatment, payment, and health care operations to provide you with quality health care.

What are your rights as a patient while being treated at Footprints in Time Midwifery Services?

• Access to emergency services: This can be accomplished by utilizing the 911 services or choosing to seek emergency services elsewhere. FITMS is not an emergency care center.
• Choice of providers: You have the choice of providers, however if you choose another provider, you will no longer receive care at FITMS as there is only one Midwife for OB Care. For Family Practice care there are two Family Nurse Practitioners. There are two Registered Nurses on staff for assistance at births and during clinic hours. We will however, send copies of your records to your new provider once a release of information has been signed by you.
• Sharing in decision making in your own health care: You have the right to know your treatment options, results of all labs and other diagnostic procedures, and to take part in the decision-making process. You also have the right to time for consideration of those options before making a decision if safety permits.
• Treated with respect and non-discrimination: You have the right to considerate, respectful, non-judgmental and non-discriminatory care from your health care providers.
• Complaints and appeals: You have the right to a fair, fast and objective review of any complaint you may have against your health care providers. This includes complaints about waiting time, operating hours, the actions of your health care providers and adequacy of the facility.

What are my consumer responsibilities while receiving care at Footprints in Time?

• In a health care system that protects patient’s rights, patients should expect to take on some responsibilities to get well and/or stay well (for instance, exercising on a regular basis and not using tobacco).
• Patients are expected to treat their health care provider with the same respect afforded to you.
• Patients are expected to ask questions, review handouts and make informed decisions in their plans of care.
• Patients are expected to pay their bills as outlined in their contracts for service agreements.
• Having patients involved in their health care increases the chance of the best possible outcomes and helps support a high quality, cost-conscious health care system.

Use and Release of Your Health Information for Treatment, Payment, and Health Care Operations: FITMS has to use and release some of your health information to conduct its business. We are permitted to use and release health information without authorization from you. Treatment includes sharing information among health care providers involved in your care.  For example, your health care provider may share information about your condition with radiologists or other consultants to make a diagnosis. FITMS may use your health information as required by your insurer to determine eligibility or to obtain payment for your treatment. In addition, FITMS may use and disclose your health information to improve the quality of care, and for education and training purposes of FITMS students, residents, and faculty.

How Will FITMS Use and Disclose My Health Information? Your health information may be used for the following purposes unless you ask for restrictions on a specific use or disclosure:

Note:  You will have the opportunity to refuse some of these communications about your health information, indicated by (*).

• Family members or close friends involved in your care or payment for treatment. (*)
• Disaster relief agency if you are involved in a disaster relief effort. (*)
• Health Information Exchange. HIE is a secure computer system for health care providers to share your health information to support treatment, healthcare operations and continuity of care. Your record in the HIE includes medicines (prescriptions), lab and test results, imaging reports, conditions, diagnoses or health problems. To ensure your health information is entered into the correct record, also included are your full name, birth date and social security number. All information contained in the HIE is kept private and used in accordance with applicable state and federal laws and regulations (FITMS is not currently using this system).
• Appointment reminders.
• Public health activities, including disease prevention, injury or disability; reporting births and deaths; reporting reactions to medications or product problems; notification of recalls; infectious disease control; notifying government authorities of suspected abuse, neglect, or domestic violence.
• Health oversight activities, such as audits, inspections, investigations, and licensure.
• Law enforcement, as required by federal, state or local law.
• Lawsuit and disputes, in response to a court or administrative order, subpoena, discovery request or another lawful request.
• Coroners, medical examiners, and funeral directors.
• Organ and tissue donation.
• Certain research projects.
• To prevent a serious threat to health or safety.
• To military command authorities if you are a member of the armed forces or a member of a foreign military authority.
• National security and intelligence activities to authorized persons to conduct special investigations.
• Workers’ Compensation. Your medical information regarding benefits for work-related injuries and illnesses may be released as appropriate.
• To carry out health care treatment, payment, and operations functions through business associates, such as to install a new computer system.

Your Authorization Is Required for Other Disclosures.  Your authorization will be required for most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that constitute a sale of protected health information. Except as described above, we will not use or disclose your medical information, unless you provide FITMS permission in writing. For example, we will not use your photographs for presentations outside the Birth Center without your written permission. You may withdraw or revoke your permission, which will be effective only after the date of your written withdrawal.

Alcohol and drug abuse information has special privacy protections. FITMS will not disclose any information identifying an individual as being a patient or provide any health information relating to the patient’s substance abuse treatment unless the patient authorizes in writing; to carry out treatment, payment, and operations; or, as required by law.

You Have Rights Regarding Your Health Information. You have the following rights regarding your medical information, if requested on the form(s) provided by FITMS:

• Right to request restriction. You may request limitations on your health information that we use or disclose for health care treatment, payment, or operations, although we are not required to comply with your request. For example, you may ask us not to disclose that you have had a particular procedure. We will release the information, if necessary, for emergency treatment. We will notify you in writing whether we honor your request or not.
• Right to confidential communications. You may request communications of your health information in a certain way or at a certain location, but you must tell us how or where you wish to be contacted.
• Right to inspect and copy. You have the right to review and obtain a copy of your medical or health record. Psychotherapy notes may not be inspected or copied. We may charge a fee for copying, mailing, and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed health care professional chosen by FITMS. FITMS will comply with the outcome of the review.
• Right to request amendment. If you believe that the health information we have about you is incorrect or incomplete, you may request an amendment on the form provided by FITMS.  FITMS is not required to accept the amendment.
• Right to accounting of disclosures. You may request a list of the disclosures of your health information that have been made to persons or entities during the past six (6) years prior to the request, except for disclosures for health care treatment, payment and operations, and disclosures based on patient authorization, or as required by law. After the first request, there may be a charge.
• Right to restrict certain disclosures to a Health Plan. You may request a restriction of certain disclosures of your protected health information to a health plan if you have paid out of pocket in full for the health care item or service.
• Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may obtain an electronic copy of this Notice at our website: www.footprintsmidwifery.com.

Requirements Regarding This Notice. FITMS is required by law to provide you with this Notice. We will comply with this Notice for as long as it is in effect. FITMS may change this Notice, and these changes will be effective for health information we have about you, as well as any information we receive in the future. Each time you register at FITMS for health services, you may receive a copy of the Notice in effect at the time.

Complaints.  If you believe your privacy rights have been violated, you may file a complaint with:

Footprints in Time Midwifery Services	Office of Civil Rights
ATTN: Privacy Officer	U.S. Department of Health and Human Services
502 Main Street	200 Independence Avenue, S.W.
Black River Falls, WI 54615	Room 509 F, HHH Building
(715)284.2003	Washington, D.C. 20201

We will not penalize or retaliate against you in any way for making a complaint to Footprints in Time or to the Department of Health and Human Services.  We will notify you in the unlikely event of a breach of your unsecured protected health information.

Contact Footprints in Time’s Privacy Officer at (715) 284-2003 if:

• You have any questions about this Notice
• You wish to request restrictions on uses and disclosures for health care treatment, payment, or operations
• You wish to obtain a form to exercise your individual rights.