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.

Your Health Care Information - Protecting Your Privacy
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.

Merton Fire Department’s Responsibilities
It is your right as a patient to be informed of Merton Fire Department’s legal duties with respect to protection of the privacy of your personal health information.

Merton Fire Department is required to:

· Maintain the privacy of your health information;
· Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; and
· Abide by the terms of this notice.

Merton Fire Department reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. Merton Fire Department also reserves the right change the terms of its notice with respect to any applicable more limited uses and disclosures.

Merton Fire Department will promptly revise and distribute its notice whenever Merton Fire Department makes a substantial change to any of its privacy practices.

Merton Fire Department will not use or disclose your health information without your authorization, except as described in this notice.

Your Health Information Rights

You have the right to:
· Request a restriction on certain uses and disclosures of your health information.
You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or Merton Fire Department’s payment or health care operation activities. However, Merton Fire Department is not required to agree to your requested restriction. For example, if you are an employee of the clinic and you receive health care services in the clinic, you may request that your health care record not be maintained in the general record filing area.
 Receive Confidential Communications.
You have the right to request that Merton Fire Department communicate your health information to you by alternative means or at alternative locations. Merton Fire Department shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record.
· Inspect and obtain a copy of your health record.
You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be in submitted in writing to Chief John Leidel. This right may not apply to certain types of psychotherapy notes and Merton Fire Department may charge you a reasonable fee for a copy of your health care record. For example, you may request a copy of your health care record from your family physician.
· Amend your health record.
You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health record should be changed. If Merton Fire Department did not create the health information you believe is incorrect or if Merton Fire Department disagrees with you, Merton Fire Department may deny your request. For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended.
· Obtain an accounting of disclosures of your health information.
You have the right to an accounting of disclosures of your health information that Merton Fire Department has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. You will receive one accounting per year at no charge and Merton Fire Department may charge you a reasonable fee for each subsequent request. For example, you may request an accounting of disclosures made from your health record in the last year to the State for disease reporting.
· Obtain a paper copy of the notice upon request.
You have the right to obtain a paper copy of the notice upon request. For example, if you received the notice electronically, you may request that Merton Fire Department provide a paper copy of the notice.
Uses and Disclosures for Treatment, Payment and Health Care Operations

Merton Fire Department is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.

Merton Fire Department may use or disclose your health information for treatment.
Merton Fire Department may use or disclose your health information in the provision, coordination or management of your health care.

Merton Fire Department may use or disclose your health information for payment.
Merton Fire Department may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis and your treatment.

Merton Fire Department may use or disclose your health information for routine health care operations.
Merton Fire Department may use or disclose your health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.

Example: Merton Fire Department may review your health record to determine the efficiency of the services provided to you.

Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization
Without your written authorization, Merton Fire Department may use or disclose your health information for the following purposes:

As Required by Law: Merton Fire Department may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:

· Disclosures about victims of elderly or child abuse;
· Disclosures for judicial and administrative proceedings; or
· Disclosures for law enforcement purposes.

Public health: As required by law, Merton Fire Department may disclose your protected health information to the State of Wisconsin for the purpose of statutory reporting.

Merton Fire Department may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.

Merton Fire Department may disclose your protected health information excluding your HIV test result without your authorization to a county agency investigating child abuse.

Merton Fire Department may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result without your authorization to the Food and Drug Administration (FDA).

Merton Fire Department may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.

Merton Fire Department may disclose your protected health information that is reasonably related to a work related illness or injury if an application for workers’ compensation has been filed.

Victims of abuse, neglect or domestic violence: Merton Fire Department may disclose health information except for an HIV test result if Merton Fire Department reasonably believes that an individual is a victim of child or elderly abuse.

Health oversight activities: Merton Fire Department will not disclose HIV test results to health care oversight agencies without an authorization. Merton Fire Department may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your protected health information may be disclosed without your authorization to a state or federal agency.

Judicial and Administrative Proceedings: Merton Fire Department may disclose your protected health information in response to a court order. Merton Fire Department may disclose your protected health information in response to a subpoena if Merton Fire Department is a party to a court action, Merton Fire Department has received your authorization to disclose and has not complied within two business days or Merton Fire Department failed to respond to a request for workers’ compensation records. Merton Fire Department may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result in response to a subpoena from a state or federal agency.

Law enforcement: Merton Fire Department may disclose your protected health information except for HIV test results to county law enforcement officials for the reporting and investigation of elderly and/or child abuse. Merton Fire Department may disclose your protected health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results to state and federal law enforcement officials. Merton Fire Department may disclose mental health, alcohol or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. Merton Fire Department may disclose your protected health information to a law enforcement official in response to a court order.

For activities related to death:
Coroner or Medical Examiner: Merton Fire Department may use or disclose your protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse and developmental disabilities to a coroner or medical examiner.

To avoid a serious threat to health or safety: Merton Fire Department may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.
Disclosures for specialized government functions: Merton Fire Department may disclose protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result for national security, for protection of the President and for medical suitability determination or of Armed Forces personnel to a state or federal agency.

Workers compensation: Merton Fire Department may disclose protected health information reasonably related to a workers’ compensation injury.

Merton Fire Department has attempted to explain with this notice the circumstances where state law may be more protective than the federal privacy rule and provides greater privacy protection.

Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your health information requires Merton Fire Department to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to Merton Fire Department’s Privacy Officer.

Patient Complaint Process

If you believe your privacy rights have been violated, you may file a complaint with Merton Fire Department or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint.

To file a complaint with Merton Fire Department please contact the Merton Fire Department Privacy Officer who will provide you with the necessary assistance.

Questions or Concerns

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:

Chief John Leidel
Merton Fire Department
P.O. Box 911
Merton, WI. 53056
(262) 538-1012

Effective Date: This Notice of Privacy Practice is effective as of April 14, 2003.