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Privacy Statement


Click to download a copy of the Waukesha Heart Institute Privacy Statement. [PDF]

Effective: January 2015


Medical Records Clerk
Waukesha Heart Institute
Mailing Address: 1111 Delafield St, Suite 215
Waukesha, WI 53188

Telephone:  262 542-0074

About This Notice

We are required by law to maintain the privacy of Protected Health Information (PHI) and to give you this Notice explaining our privacy practices with regard to that information. You have certain rights – and we have certain legal obligations – regarding the privacy of your Protected Health Information, and this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.

What is Protected Health Information?

“Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.

The health information about you is personal. A record of the care and services you receive is needed to provide you with quality care and to comply with legal requirements.

The law requires us to:

  • Make sure that health information that identifies you is kept private.
  • Give you this Notice of our legal duties and privacy practices with respect to health information about you.
  • Notify you in the event of a breach of your unsecured PHI.
  • Follow the terms of this Notice that are currently in effect.

In Certain Circumstances We May Use And Disclose PHI About You Without Your Written Consent

  • For Treatment: We will use health information about you to provide you with medical treatment or services. We will disclose PHI about you to doctors, residents, nurses, technicians, students in health care training programs, or other personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes might slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the Waukesha Heart Institute may share health information about you in order to coordinate the services you need, such as prescriptions, lab work and x-rays. We may disclose health information about you to people outside Waukesha Heart Institute who provide your medical care. For example, we may provide information about your care and treatment to a doctor or nursing home that provides your care following your hospital or clinic services.
  • For Payment: We will use and disclose your PHI to send bills and collect payment from you, your insurance company, or other payers, such as Medicare, for the care, treatment, and other related services you receive. We may provide your name, address and insurance information to other health care providers related to your care. We may tell your health insurer about a treatment your doctor has recommended to obtain prior approval to determine whether your plan will cover the cost of the treatment. For billing information, contact the Billing Department.
  • For Health Care Operations: We may use and disclose PHI about you for the purpose of our business operations. These business uses and disclosures are necessary to make sure that our patients receive quality care and cost effective services. For example, we may use PHI to review the quality of our treatment and services, and to evaluate the performance of our staff in caring for you. We may use or disclose your PHI to an outside company that assists us in operating our clinic. For example, when your doctor dictates a summary of the visit with you, an outside company types up the document for our medical records. These outside companies are called “business associates”, who have contracted with us to keep any PHI received from us confidential in the same way we do.
  • Family Members and Friends: We may disclose PHI about you to a family member, relative, or another person identified by you who is involved in your health care or payment for your health care. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited PHI is in your best interest under the circumstances.
  • Hospital/Clinic Directory: When you are an inpatient admitted to the hospital, or are admitted as an outpatient to the clinic, the Waukesha Heart Institute may list certain information about you, such as your name, your location in the hospital, and your religious affiliation in a hospital directory. The hospitals can disclose this information, except for your religious affiliation, to people who ask for you by name. Your religious affiliation may be given to members of the clergy even if they do not ask for you by name. You may request that no information contained in the directory be disclosed. To restrict use of information listed in the directory, please inform the admitting staff or your nurse. They will assist you in this request. In emergency circumstances, if you are unable to communicate your preference, you will be listed in the directory.
  • Future Communications: We may use your name, address, and phone number to contact you to provide you information about new programs or other services we offer, or Waukesha Heart Institute newsletters. An example of this would be mailers to all patients regarding a walk or run for cardiovascular disease. This same information may be used to develop new programs as part of promoting health.
  • Public Health and Government Functions: We will disclose your PHI in certain circumstances to:
    • Control or prevent a communicable disease, injury or disability, to report births and deaths, and for public health oversight activities or interventions.
    • The Food and Drug Administration (FDA), to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law.
    • To a state or federal government agency to facilitate their functions.
  • Required or Permitted by Law: We will disclose your PHI when required to do so by federal, state, or local law.  We are permitted, and required in some cases, to release your PHI in certain circumstances to:
    • Report suspected elder or child abuse to law enforcement or other governmental agencies responsible to investigate or prosecute abuse.
    • Respond to a valid court order.
    • The Department of Health Services (DHS), the Department of Children and Families (DCF), a protection or advocacy agency, law enforcement authorities investigating abuse, neglect, physical injury, death, and suspicious wounds, burns, or gunshot wounds.
    • Your court appointed guardian or agent you have appointed under a health care power of attorney.
    • A prisoner’s health care provider.
    • A medical examiner, coroner, and funeral director regarding a death.
    • Law enforcement officials with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons.
  • Organ, Eye and Tissue Donation: We will disclose PHI to organizations that obtain, bank or transplant organs or tissues.
  • Research: Waukesha Heart Institute may use and share your health information for certain kinds of research. Waukesha Heart Institute has a research review board that reviews and approves research projects. The review board may approve using your health information without your written authorization when the board determines that the researcher will follow all privacy rules. Other research projects submitted to the review board will require your written authorization to use the information before the research begins. Whether or not your health information is used in a research project, your care and treatment will not be affected.
  • Workers’ Compensation: We will disclose your health information that is reasonably related to a worker’s compensation illness or injury following written request by your employer, worker’s compensation insurer, or the Department of Workforce Development or its representative.
  • Employer Sponsored Health and Wellness Services: We maintain PHI about employer sponsored health and wellness services we provide our patients, including services provided at their employment site. We will use the PHI to provide you medical treatment or services and will disclose the information about you to others who provide you medical care. For employer sponsored services provided at your employment site, summary, de-identified information may be provided to your employer for planning purposes. If you wish to have detailed health information provided to your employer, you must complete an authorization for release of PHI.
  • Shared Medical Record/Health Information Exchanges: We maintain PHI about our patients in shared electronic medical records that allow the Waukesha Heart Institute to share PHI. We also participate in various electronic health information exchanges that facilitate access to PHI by other health care providers who provide you care. For example, if you are admitted on an emergency basis to another hospital that participates in the health information exchange, the exchange will allow us to make your PHI available electronically to those who need it to treat you at the hospital.

Your Protected Health Information Rights

Right to Request Restrictions: You have the right to request certain restrictions of our use or disclosure of PHI for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care or the payment for your care. We are not required to agree to your request in most cases. If Waukesha Heart Institute agrees to the restriction, it will comply with your request unless the information is needed to provide you emergency treatment. We must, however, agree to your request to (1) restrict our disclosure of your PHI to your health plan when you have paid us out-of-pocket in full for the health care item or service we provided you, (2) restrict our disclosure of your immunization data to the Wisconsin Immunization Registry. A request for restriction should be made in writing. To request a restriction, please contact the Medical Records Clerk.

Right to Inspect and Copy: You have the right to inspect and receive a copy of PHI about you that may be used to make decisions about your health. A request to inspect your records may be made to your nurse or doctor while you are an inpatient or to the Medical Records Clerk while an outpatient. For copies of your PHI, requests must go to the Medical Records Clerk. There may be a charge for these copies. For copies of billing records, you may contact our Billing Department.

Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information, for as long as the Waukesha Heart Institute maintains the information. Requests for amending your PHI should be made to the Medical Records Clerk. The Waukesha Heart Institute will respond to your request within 60 days after you submit the written amendment request form. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Right to a List of Disclosures: You have the right to request a list of instances in which we or our business associates disclosed your PHI for purposes other than treatment, payment, health care operations, disclosures authorized by you or made to you, and certain other activities. To request this list of disclosures, you must submit your request in writing to the designated Health Information/Medical Records Department. The first list you request from Waukesha Heart Institute within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Alternate Means of Communication: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location. We will accommodate all reasonable requests. You must make any such request in writing submitted to the Medical Records Clerk.

Right to Require Authorization: Your authorization is required for most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI.

Right to Revoke Authorization: If you authorize the Waukesha Heart Institute to use or disclose your PHI, you may revoke that authorization, in writing, at any time. We are unable to take back any disclosures we have already made with your permission. To revoke an authorization you must contact the Medical Records Clerk.

How to Exercise Your Rights

To exercise your rights described in this Notice, send your request, in writing, to our Medical Records Clerk at the address listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To exercise your right to inspect and copy your Protected Health Information, you may also contact your physician directly. To get a paper copy of this Notice, contact our Medical Records Clerk by phone or mail.

Changes To This Notice

We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for Protected Health Information we already have as well as for any Protected Health Information we create or receive in the future. A copy of our current Notice is posted on our website.


You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated.

To file a complaint with us, contact our Medical Records Clerk at the address listed at the beginning of this Notice. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint.

To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you for filing a complaint.

Important Notice: We reserve the right to revise or change this Notice and to make the new Notice provisions effective for all PHI the that the Waukesha Heart Institute maintain. Each time you register for health care services at a site covered by this Notice, the most current copy of this Notice will be available for you. You have a right to obtain a paper copy of this Notice upon request.