and Westside Occupational Health
To our patients: This notice describes how health information about you
(as a patient of this practice) may be used and disclosed, and how you can
get access to this information. Please review it carefully. This includes
protecting your actual medical record. Billing information and electronic
transmissions, faxes and phone calls that may include medical information.
We are also making our best effort to ensure that any associates that may
have access, protect your patient information. This is required by the Privacy
Regulations created as a result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). Understand that the minimum information
possible will be released.
Our Commitment to Your Privacy
Our practice is dedicated to maintaining the privacy of your health information.
We are required by law to maintain the confidentiality of your health information.
We realize that these laws are complicated, but we must provide you with
the following important information:
We will not use or disclose your medical information for any purpose not
listed below, without your specific written authorization. Any specific
written authorization you provide may be revoked at any time by writing
1. Public health authorities and health oversight agencies that are authorized
by law to collect information.
2. Lawsuits and similar proceedings in response to a court or administered
3. If required to do so by a law enforcement official. Under certain circumstances,
we may disclose health information to law enforcement officials as required
by law. These would include: certain types of wounds, pursuant to certain
subpoenas or court orders, suspected victims of crimes, crimes on our premises,
and crimes in emergencies.
4. We may disclose medical information to appropriate authorities if we
reasonably believe that you are a possible victim of abuse, neglect or domestic
violence or the possible victim of other crimes. We may share medical information
when necessary to help law enforcement officials capture a person who has
admitted to being a part of a crime or has escaped from legal custody.
5. When necessary to reduce or prevent a serious threat to your health and
safety or the health and safety of another individual or the public. We
will only make disclosures to a person or organization able to help prevent
6. If you are a member of US or foreign military forces (including veterans)
and if required by the appropriate authorities, information will be released.
7. Information may be shared with Federal officials for intelligence and
national security activities authorized by law.
8. Correctional institutions or law enforcement officials may receive information
if you are an inmate or under the custody of a law enforcement official.
9. Patients with occupational injuries will have information released. By
Iowa law, the employer has the right to medical information about your injury.
Information pertinent to the injury only will be released to your employer
or his representatives including, nurse care managers, insurance companies,
adjusters, and repricing companies.
10. The sources referring you to this clinic. Information may be shared
with your referring physician.
11. Other entities involved in your testing, care and treatment. Example:
hospital staff, physical therapy and pharmacy staff and any facility that
we may refer you to.
12. Certain information may be shared with agencies or companies to secure
approval for tests or treatment that you may need.
13. Your insurance company including a third party clearing house, billing
service, repricing companies, and managed care companies.
14. You may also receive informational mailings from Westside. We will never
share or sell your information to any outside party.
15. Westside Orthopaedics has the right to collect fees from you for service
received. Every effort is made to protect your personal health information
in the unfortunate event that your account should be sent to a collection
agency. We do not release diagnosis information, but by law the collection
agency must be able to tell you what your charges were for.
16. Patient information may also be reviewed as needed by Westside staff
in day to day operation of the clinic including statistical information,
collections and practice operations and management.
and the terms of this notice from time to time provided that the changes
are permitted by law.
18. Medical information to notify or help notify: a family member, your
personal representative, or another person responsible for your care. In
case of emergency, and if you are not able to give or refuse permission,
we will share only the health information that is directly necessary for
your health care, according to our professional judgment. We will also use
our professional judgment to make decisions in your best interest about
allowing someone to pick up medicine, medical supplies, x-ray or medical
information for you.
19. To help them carry out their duties, we may share the medical information
of a person who has died with a coroner, medical examiner, funeral director,
or an organ procurement organization.
20. Messages may be left on your answering machine regarding care or as
appointment reminders. Appointment reminder cards may also be sent.
21. At times Westside Orthopaedics may hire Business Associates who may
have access to your Protected Health Information. These Associates are required
to protect the privacy on our patients and comply with state and federal
law in keeping your Protected Health Information confidential. An example
would be a computer software vendor who services the programs we use.
Your Rights Regarding Your Health Information
1. Communications. You can request that our practice communicate with you
about your health and related issues in a particular manner or at a certain
location. For instance, you may ask that we contact you at home, rather
than work. We will accommodate reasonable written requests.
2. You can request a restriction in our use or disclosure of your health
information for treatment, payment, or health care operations. Additionally,
you have the right to request that we restrict our disclosure of your health
information to only certain individuals involved in your care or the payment
for your care, such as family members and friends. We are not required to
agree to your request; however, if we do agree, we are bound by our agreement
except when otherwise required by law, in emergencies, or when the information
is necessary to treat you.
3. Right to a copy of this notice. You are entitled to receive a copy of
this Notice of Privacy Practices. You may request a copy of this Notice
any time. To obtain a copy of this notice, please complete a Request for
Record Form available from our front desk receptionist or put your request
4. Right to file a complaint. If you believe your privacy rights have been
violated, you may file a complaint with our practice or with the Secretary
of the Department of Health and Human Services. To file a complaint with
our practice, contact: Margy M. Schulte, Practice Administrator, Westside
Orthopaedics, 4005 Westmark Dr. Ste. 200, Dubuque, Iowa 52002. All complaints
must be submitted in writing. You will not be penalized for filing a complaint.
We are very interested in correcting any violation of your privacy.
5. Right to provide an authorization for other uses and disclosures. Our
practice will obtain your written authorization for uses and disclosures
that are not identified by this notice or permitted by applicable law.
6. You also have a right to receive a list of all the items we or our business
associates shared your medical information for purposes other than treatment,
payment, and health care operations and other specified exceptions. If you
wish to receive such a list, please put your request in writing.
7. You have a right to request that we change your medical information.
We may deny your request if we did not create the information you want changed
or if we do not believe the information in your record is inaccurate 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
that will be added to the information you wanted changed. If we accept your
request to change your information, we will provide an addendum to your
record and make reasonable efforts to tell others, including people you
name, of the change and to include the changes in any future sharing of
If you have any questions regarding this notice or our health information
privacy policies, please contact Westside Orthopaedics, 4005 Westmark Dr.,
Ste 200, Dubuque, Iowa 52002, Attention: Margy Schulte, Practice Administrator,
or call: 563-582-6202
Effective Date: April 14, 2003