Quality Addiction Management of Wisconsin

Privacy Policy Notice

We respect the privacy of our patients. We do not disclose any information to any party unless expressly approved in writing by the patient.

We follow 42 CFR Part 2 of the federal rules.

Notice of Privacy Practices

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.

Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical
record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. The only health plan QAM presently accepts is Wisconsin Medicaid.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of Quality Addiction Management (QAM). For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
Fund raising. QAM does not engage in fund raising activities.

Individual Rights
You have certain rights under the federal privacy standards.
These include:
◆ the right to request restrictions on the use and disclosure of your protected health information
◆ the right to receive confidential communications concerning your medical condition and treatment
◆ the right to inspect and copy your protected health information
◆ the right to amend or submit corrections to your protected health information
◆ the right to receive an accounting of how and to whom your protected health information has been disclosed
◆ the right to receive a printed copy of this notice

QAM Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. This notice takes effect March 31, 2009 and remains in effect until we replace it.

Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting your counselor or the Administrator.

Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

Elizabeth Gilbert, R.N., Administrator
Quality Addiction Management
2422 N. Grandview Blvd.
Waukesha, WI 53188

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person
The name and address of the person you can contact for further information concerning our privacy practices is:

Elizabeth Gilbert, MBA, R.N., Administrator
Quality Addiction Management
2422 N. Grandview Blvd.
Waukesha, WI 53188
Telephone: 262-549-6600

Effective Date
This Notice is effective beginning March 31, 2009.

Quality Addiction Management

©QAM 3/2011

We offer several Wisconsin Locations to help speed recovery. Contact us today.