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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. USE AND DISCLOSURE OF HEALTH INFORMATION Milwaukee Regional Medical Center/Flight For Life ( MRMC/Flight For Life ) may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. MRMC/Flight For Life has established a policy to guard against unnecessary disclosure of your health information. THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED: To Provide Treatment . MRMC/Flight For Life may use your health information to provide care to you and disclose your health information to others who provide care to you. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. MRMC/Flight For Life also may disclose your health care information to individuals outside of MRMC/Flight For Life involved in your care including family members, pharmacists, suppliers of medical equipment or other health care professionals. To Obtain Payment . MRMC/Flight For Life may include your health information in invoices to collect payment from third parties for the care you may receive from us. For example, MRMC/Flight For Life may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or MRMC/Flight For Life. MRMC/Flight For Life also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you. To Conduct Health Care Operations . MRMC/Flight For Life may use and disclose health information for its own operations in order to facilitate the function of MRMC/Flight For Life and as necessary to provide quality care to all of MRMC/Flight For Life's patients. Health care operations include activities such as: - Quality assessment and improvement activities. - Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment. - Professional review and performance evaluation. - Training programs including those in which students, trainees or practitioners in health care learn under supervision. - Training of non-health care professionals. - Accreditation, certification, licensing or credentialing activities. - Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs. - Business planning and development including cost management and planning related analyses and formulary development. - Business management and general administrative activities of MRMC/Flight For Life. - Fundraising for the benefit of MRMC/Flight For Life and certain marketing activities. For example, MRMC/Flight For Life may use your health information to evaluate its staff performance, combine your health information with other MRMC/Flight For Life patients in evaluating how to more effectively serve all of MRMC/Flight For Life's patients, disclose your health information to MRMC/Flight For Life staff and contracted personnel for training purposes, use your health information to contact you or your family as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted). For Fundraising Activities . MRMC/Flight For Life may use information about you including your name, address, telephone number and the dates you received care by MRMC/Flight For Life in order to contact you or your family to raise money for MRMC/Flight For Life. If you do not want MRMC/Flight For Life to contact you or your family, you must notify the Program Director at 414-805-6427 and indicate that you do not wish to be contacted. When Legally Required . MRMC/Flight For Life will disclose your health information when it is required to do so by any Federal, State or local law. When There Are Risks to Public Health . MRMC/Flight For Life may disclose your health information for the following public activities and purposes: - To prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions. - To report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketi20 February, 2004 Drug Administration. - To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease. - To an employer about an individual who is a member of the workforce as legally required. To Report Abuse, Neglect Or Domestic Violence . MRMC/Flight For Life is allowed to notify government authorities if MRMC/Flight For Life believes a patient is the victim of abuse, neglect or domestic violence. MRMC/Flight For Life will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure. To Conduct Health Oversight Activities . MRMC/Flight For Life may disclose your health information to a health oversight agency for activities including: audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action. MRMC/Flight For Life, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to your receipt of health care or public benefits. In Connection With Judicial And Administrative Proceedings . As permitted or required by State law, MRMC/Flight For Life may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process. Reasonable efforts will be made to either notify you about the request or to obtain an order protecting your health information. For Law Enforcement Purposes . As permitted or required by State law, MRMC/Flight For Life may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime. To Coroners And Medical Examiners . MRMC/Flight For Life may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law. To Funeral Directors . MRMC/Flight For Life may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, MRMC/Flight For Life may disclose your health information prior to, and in reasonable anticipation of, your death. For Organ, Eye Or Tissue Donation . MRMC/Flight For Life may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation. For Research Purposes . MRMC/Flight For Life may, under very select circumstances, use your health information for research. Before MRMC/Flight For Life discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. In the Event of A Serious Threat To Health Or Safety . MRMC/Flight For Life may, consistent with applicable law and ethical standards of conduct, disclose your health information if MRMC/Flight For Life, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. For Specified Government Functions . In certain circumstances, the Federal regulations authorize MRMC/Flight For Life to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody. For Worker's Compensation . MRMC/Flight For Life may release your health information for worker's compensation or similar programs. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than is stated above, MRMC/Flight For Life will not disclose your health information other than with your written authorization. If you or your representative authorizes MRMC/Flight For Life to use or disclose your health information, you may revoke that authorization in writing at any time. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION You have the following rights regarding your health information that MRMC/Flight For Life maintains: Right to Request Restrictions . You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on MRMC/Flight For Life's disclosure of your health information to someone who is involved in your care or the payment of your care. However, MRMC/Flight For Life is not required to agree to your request. If you wish to make a request for restrictions, please contact the Program Director at 414-805-6427. Right to Receive Confidential Communications . You have the right to request that MRMC/Flight For Life communicate with you in a certain way. For example, you may ask that MRMC/Flight For Life only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact the Program Director at 414-805-6427. MRMC/Flight For Life will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications. Right to Inspect and Copy Your Health Information . You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to the Program Director at 414-805-6427. If you request a copy of your health information, MRMC/Flight For Life may charge a reasonable fee for copying and assembling costs associated with your request. Right to Amend Your Health Information . You or your representative have the right to request that MRMC/Flight For Life amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by MRMC/Flight For Life. A request for an amendment of records must be made in writing to MRMC/Flight For Life - Program Director at 9000 W. Wisconsin Ave. Milwaukee , WI . 53226. MRMC/Flight For Life may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by MRMC/Flight For Life, if the records you are requesting are not part of MRMC/Flight For Life's records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of MRMC/Flight For Life, the records containing your health information are accurate and complete. Right to an Accounting . You or your representative have the right to request an accounting of disclosures of your health information made by MRMC/Flight For Life for certain purposes, which may include disclosures required by law and disclosures for certain public health activities. The request for an accounting must be made in writing to MRMC/Flight For Life - Program Director at 9000 W. Wisconsin Ave. Milwaukee , WI . 53226 . The request should specify the time period for the accounting starting on April 14, 2003 . Accounting requests may not be made for periods of time in excess of six (6) years. MRMC/Flight For Life will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. Right to a Paper Copy of this Notice . You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact MRMC/Flight For Life - Program Director at 414-805-6427 A patient or a patient's representative may also obtain a copy of the current version of MRMC/Flight For Life's Notice at its Web site, www.flightforlife.org. DUTIES OF MRMC/FLIGHT FOR LIFE MRMC/Flight For Life is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. MRMC/Flight For Life is required to abide by the terms of this Notice as may be amended from time to time. MRMC/Flight For Life reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If MRMC/Flight For Life makes a material change to this Notice, MRMC/Flight For Life will distribute a copy of the revised Notice. You or your representative have the right to express complaints to MRMC/Flight For Life and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to MRMC/Flight For Life should be made in writing to MRMC/Flight For Life - Program Director at 9000 W. Wisconsin Ave. Milwaukee , WI . 53226. MRMC/Flight For Life encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. CONTACT PERSON MRMC/Flight For Life has designated the Program Director as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at MRMC/Flight For Life 9000 W. Wisconsin Ave. Milwaukee, WI. 53226 or at 414-805-6427. EFFECTIVE DATE This Notice is effective April 14, 2003 . IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT |
Flight For Life is a program of the Milwaukee Regional Medical Center.
© 2006. Flight For Life. All Rights Reserved.
Aviation services are provided by CJ Systems Aviation Group.
