Privacy Policy

Home/Privacy Policy
Privacy Policy 2017-05-03T16:07:03+00:00

Current Revision:  May 12, 2016

Notice of Privacy Practices Policy PDF version

Urology Specialists of Wisconsin, S.C.

Notice of Privacy Practices Policy

 

Purpose

Individuals have the right to receive adequate notice of Urology Specialists of Wisconsin, S.C.’s privacy practices and their rights with respect to their protected health information.  To establish guidelines to develop and maintain a current notice of privacy practices that summarizes this information.  To provide Urology Specialists of Wisconsin, S.C.’s notice of privacy practices in a timely manner to individuals.

Responsible for Implementation: The Privacy Officer is responsible for implementing and overseeing this policy.

Policy 

  1. It is the policy of Urology Specialists of Wisconsin, S.C. to provide individuals in a timely manner with a notice of privacy practices regarding:
    1. Uses and Disclosures of protected health information that may be made by Urology Specialists of Wisconsin, S.C.;
    2. Their rights related to their protected health information; and
    3. The Urology Specialists of Wisconsin, S.C.’s duties with respect to their protected health information.
  2. To make a good faith effort to provide the notice of privacy practices to individuals before their first treatment encounter and to obtain written acknowledgment of receipt of the notice of privacy practices.

 

Procedures

  1. The Privacy Officer is responsible for (also refer to the Privacy & Security Oversight Policy and Procedures):
    1. Creating and maintaining a current and compliant notice of privacy practices (NPP)
      1. Updates the NPP to reflect changes made to laws and Urology Specialists of Wisconsin, S.C.’s privacy policies and procedures
      2. Ensuring revised NPPs are made available to distribute as described in these procedures
    2. Educating appropriate Workforce of:
      1. The location of the current NPP; and
      2. When the NPP has been updated
      3. Provisions of another organization’s NPP they need to follow (as required by a written contract with that organization)
  2. The NPP:
    1. Is written in plain language
    2. Includes statements and elements required by Health Insurance Portability and Accountability Act (HIPAA) regulations
    3. When changes are made to it, the changes made may be effective for PHI created and received prior to the revision effective date.
  3. Only Use and Disclose PHI in a manner that is consistent with the provisions in Urology Specialists of Wisconsin, S.C.’s NPP, and another other organization’s NPP as required by a written contract with that organization.
  4. Forward questions and complaints about the NPP and acknowledgment process to the Privacy Officer.
  5. The NPP is provided to:
    1. Patients that are at least 18 years old and competent;
    2. Personal representatives (refer to the Personal Representatives Use and Disclosure Procedures), if the patient is not at least 18 years old or competent;
    3. Patients on the first service delivery date / first treatment encounter on or after their 18th birthday.
  6. Patients and residents:
    1. Front desk receptionists:
      1. Provide each patient or his/her legal guardian with a copy of Urology Specialists of Wisconsin, S.C.’s most recent version of the NPP and provide him/her with the opportunity to review it:
        (1)   On the first visit Urology Specialists of Wisconsin, S.C. (in person, over the internet (e.g. tele health), and/or over the telephone);
        (2)   In an emergency treatment situation, as soon as reasonably practical after the emergency treatment situation.
        (3)   When the first service delivery is delivered electronically provide an electronic NPP automatically and at the time of the individual’s first request for service and request the individual acknowledge receipt.
        (4)   Each future service delivery date, if an acknowledgment was not previously obtained, unless the reason was due to a refusal to sign it.
      2. After providing a copy of the NPP:
        (1)   Obtain a written acknowledgment of receipt of the NPP:
        (a)    On Urology Specialists of Wisconsin, S.C.’s Patient Demographic form for each patient.
        (b)   If the service will be provided electronically, obtain an electronic return receipt or other return transmission.
        (i)     If an electronic acknowledgment was not received within 30 days, complete an acknowledgment form / indicate in the electronic health record  it was not signed after the NPP was electronically sent
        (2)   Verify the acknowledgment signed and dated.
        (3)   As an acknowledgment is signed by all patients before they are seen, the organization does not have procedures in place to document a reason for it not being obtained.
        (4)   Acknowledgments that are e-signed are automatically stored in the electronic health record system.
        (5)   Scan the hard copy acknowledgment and save it in the patient’s chart in the registration section under additional forms.
        (a)    Properly dispose of the form according to the Disposal policy.
    2. The Privacy Officer facilitates:
      1. Having the current version of the NPP available at each physical service delivery site:
        (1)   On or after the effective date;
        (2)   For individuals to request to take with them (insert location here, such as at the front desk reception area); and
        (3)   Posted in a clear and prominent location in the waiting area where it is reasonable to expect individuals seeking service to be able to read the notice.
  7. Electronic Notice:
    1. The Privacy Officer facilitates posting the current NPP on Urology Specialists of Wisconsin, S.C.’s web site in a prominent location
    2. The NPP may be provided to individuals by e-mail (encrypted email is utilized unless requested by the individual to not use encrypted email, refer to the Technical Access Control policy) if the individual agrees to electronic NPP and such agreement has not been withdrawn
      i)        If an e-mail transmission fails, provide a paper copy of the NPP to the individual
    3. Individuals that receive electronic NPPs retain the right to request and obtain a paper copy of the NPP
  8. Documentation.  All documentation related to this policy and procedures is maintained for a minimum of six years from the date of creation or date it was last in effect, whichever is later.
  9. Reporting and Compliance:
    1. Violation of this policy and its procedures by workforce members may result in disciplinary action, up to and including termination of employment.  Violation of this policy and procedures by others, including business associates and partners may result in termination of the relationship and/or associated privileges.  Violation may also result in civil and criminal penalties as determined by federal and state laws and regulations.  Urology Specialists of Wisconsin, S.C. reserves the right to notify law enforcement authorities of any unlawful activity and to cooperate in any investigation of such activity.
    2. Urology Specialists of Wisconsin, S.C. does not consider conduct in violation of this policy to be within an workforce member’s, business associate’s, or partner’s course and scope of employment or partnership, or the direct consequence of the discharge of the employee’s or partner’s duties. Accordingly, to the extent permitted by law, Urology Specialists of Wisconsin, S.C. reserves the right not to defend or pay any damages awarded against employees or partners that result from violation of this policy.
    3. If a workforce member, business associate, or partner believes he or she has been requested to undertake an activity which he or she believes is in violation of this policy, he or she must provide a written or verbal complaint to the Privacy or Security Officer or any manager or director as soon as possible.

Key Definitions – for capitalized terms refer to the HIPAA Privacy Security Definitions document

References:

  1. HIPAA Applicability and Organizational Requirements Policy
  2. Privacy & Security Oversight Policy and Procedures
  3. Personal Representatives Use and Disclosure Procedures
  4. Designated Record Set Procedures
  5. Disposal Policy

Applicable Standards/Regulations:

  1. 45 CFR § 164.500 Applicability
  2. 45 CFR § 164.502(i) Uses and disclosures consistent with notice
  3. 45 CFR § 164.520 Notice of privacy practices for protected health information
  4. 45 CFR § 164.530(i)(2) Changes to policies and procedures
  5. Wis. Stat. §146 Miscellaneous Health Provisions, 1/1/15

 

Version History

 

Version # Effective Date: Author(s)/Editor(s): Reviewer(s): Signature line
1 11/05/12 Sue E Brudenell Sue E Brudenell
05/12/16 Sue E Brudenell Sue E Brudenell

  

URO Specialists Notice of Privacy Rights