NOTICE OF PRIVACY PRACTICES
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.
The medical staff and
employees of Lakeland Health Care Center are very concerned with
your privacy. We have, and always will, respect the privacy of
your health information. The following information describes
our confidentiality practices, and some of the conditions when
information might be disclosed with or without your permission.
We cannot give every instance when information may be disclosed, so
if you have specific questions, please ask the Medical Records
DISCLOSURES OF PROTECTED HEALTH INFORMATION
When you sign the
Lakeland Health Care Center Admission Agreement form,
you acknowledge that we will use your medical information for
purposes of treatment, payment and health care operations without
contacting you again.
- TREATMENT would include managing
your health care and related services, including
consultations/referrals within the nursing home, and referrals
to other providers outside the nursing home. For example, we
are required to give some of your information to a hospital if
you need to be admitted there, to an orthopedic doctor for
follow-up of a fracture or to a specialist who advises us on
wound care. We send all diagnoses to our pharmacy provider.
People providing hospital or therapy services would also have
access to your records.
- PAYMENT would include obtaining
premiums, determining coverage and eligibility, billing, claims,
collection, and other associated activities. For example, we
would send information to your insurance company so they will
pay your bill. We would also send your information to the
Medicare or Medicaid offices to see if you qualify and/or to pay
your bill. We will send your bill to anyone else you designate
who will be responsible for payment for your care.
- HEALTH CARE OPERATIONS would
include management-type activities which ensure quality health
care is maintained at Lakeland Health Care Center. These
include, but are not limited to, things like Quality Assurance
and Assessment, Planning, Credentialing and Licensing,
Utilization Review, Inservice Training, and Performance
Evaluations. For example, we send part of our residents’
records to the Center for Health Systems Research in Madison to
obtain a report about how we compare with other nursing homes in
WI. This area might also include activities designed to improve
health, identify alternate treatments, or reduce health care
costs. We also include training programs for students in
Other examples of
situations in which we might release information without your
consent or authorization would include:
To certain local, state, or
federal government agencies as required by law.
Filing of death certificates and investigation by the coroner or
medical examiner would be one example. Also, your record would
have to be brought to court in response to a court order.
- When there are health risks to
the resident. The
facility is allowed to notify government authorities if we
believe a resident is the victim of abuse, neglect or domestic
- When there are health risks
to the public.
Reporting of adverse events, product defects, or information
required by the Food and Drug Administration. We will notify a
person who has been exposed to a communicable disease. We will
also notify the agency responsible for surveillance,
investigation or intervention of public health issues. Things
like occurrence of communicable diseases will be included.
Information needed for organ, eye or tissue donation will also
be disclosed to the agencies involved for the purpose of
facilitating the donation and transplantation.
- For fundraising activities.
The facility might use information about you to contact you or
your family to raise money for the facility. If you do not want
us to contact you or your family, you must notify the Admission
Social Worker at 262-741-3600, and indicate that you do
not wish to be contacted.
- For facility directories.
The facility may disclose your name, where you are located in
the facility and a very general statement of your condition
while you are a resident here. The facility would disclose this
information only to people who ask for you by name. A list of
religious affiliation is maintained, and will be
disclosed only to clergy or their designees such as parish
workers. A list of armed forces veterans is also
maintained and used within the facility and by outside groups
for patriotic events. Your name and birth date will be
given to a local florist for a special gift on your birth date.
If you do not want your name on the religious affiliation list,
veterans list, or birthday list, you must notify the
Admission Social Worker at 262-741-3600.
- For research purposes.
The facility may, under very special circumstances, use your
health information for research. Before any research project is
undertaken, approval by administration will have to be obtained
to ensure individual information is protected as much as
- For Worker’s Compensation
claims, if applicable.
Any time we release information
without your consent, we will release only the minimum necessary to
achieve the purpose of the disclosure. Other than the areas
stated above, Lakeland Health Care Center will not disclose your
health information without your written authorization. If you
or your representative authorize us to use or disclose your health
information, you may revoke that authorization in writing at any
time. You cannot make this revocation retroactive however.
Please address the authorization revocation to the Medical Records
REGARDING PROTECTED HEALTH INFORMATION
You have several
rights in regard to the uses and disclosures of your health
information. These include:
- The right to request
may request restrictions on certain uses and disclosures of your
health information. For example, you can request a limit on
disclosure of your information to someone who is involved in
your care or the payment for your care. Lakeland Health Care
Center is not required to agree to your restriction, but if we
do, it will be binding on us. If you wish to make a request for
a restriction, please contact the Admission Social Worker
at 262-741-3600, or your Neighborhood Social Worker.
- The right to receive
You have the right to request that we communicate with you or
your contact person in a certain way. For example, you can
request that we speak to you without family members present, or
that we do not leave a message on the answering machine at your
contact person’s home. If you wish to request a specific
restriction on confidential communications, please contact the
Admission Social Worker at 262-741-3600, or your
Neighborhood Social Worker. We will not ask the reason for your
request, and will accommodate reasonable requests.
- The right to inspect and copy
your health information.
While the records remain the property of Lakeland Health Care
Center, you have the right to inspect and copy your health
information, including billing records. To inspect your
records, please contact your Neighborhood Social Worker
who will contact the Medical Records Department or the
billing department. We require a minimum of 24 hours notice
before such an inspection can be arranged. If you request a
copy of your health information, we will charge a reasonable fee
for copying and assembling costs associated with your request.
You will be informed of the copying fee prior to making the
record copies. The fee is due at the time you receive the
- The right to amend your health
information. You have
the right to request that Lakeland Health Care Center amend your
records if you believe the information is incorrect or
incomplete. That request may be made as long as the record is
maintained by the facility. A request for amendment of records
must be made in writing to the Medical Records
Coordinator at Lakeland Health Care Center. The facility may
deny the request if it is not in writing, or does not include a
reason for the amendment. We may also deny the request if the
records in question were not created by us, or if, in our
opinion, the information is accurate and complete. In the case
of a denial of your request, you will be allowed to write your
own version of the contested information, and sign and date your
entry. This additional information will then become part of the
medical record and will be released any time the contested
information is released.
- The right to receive an
accounting of the disclosures of your health information.
You have the right to request a record of disclosures of your
health information made by us for any reason other than for
treatment, payment or health operations. The request for an
accounting must be made in writing to the Medical Records
Coordinator at Lakeland Health Care Center. The request should
specify the time period for the accounting, starting no sooner
than April 14, 2003. Accounting requests may not be made for
periods of time in excess of six (6) years. We will provide the
first accounting you request during any 12-month period without
charge. Subsequent requests may be subject to a reasonable
- The right to receive a paper
copy of this Notice.
You have a right to receive a paper copy of this Notice at any
time, even if you have received this Notice previously. To
obtain a separate paper copy, please contact your Social Worker.
A copy is also available on the County Web site at
or in the lobby of this facility.
LAKELAND HEALTH CARE
CENTER’S DUTIES RELATED TO PROTECTED HEALTH INFORMATION
Lakeland Health Care
Center is required by law to maintain the privacy of your health
information, and to provide you this Notice of its duties and
privacy practices. We are required to abide by the terms of
this Notice. However, we reserve the right to change the terms
of the Notice, and to make the new provisions effective for all
health information we maintain. In that case, we would post a
notice on our web site and at a prominent location within the
facility, stating that change(s) have been made and providing the
You have the right to
express complaints to Lakeland Health Care Center and to the
Secretary of Health and Human Services if you believe that your
privacy rights have been violated. Any complaints to Lakeland
Health Care Center should be made in writing to the Medical
Records Coordinator. Inquiries about the complaint procedure
or any of the provisions in this Notice can also be made to the
Medical Records Coordinator via phone at 262-741-3600. We
encourage you to express any concerns/ complaints you might have,
without fear of retaliation in any way.
This Notice is
effective April 14, 2003.
Rev. 3-10-03, 2/16/09