policies | Csipmadison

Clinical Policies

Attendance

Due to the high demand for psychiatric services, if you miss your initial psychiatric intake appointment without providing at least 24 hours’ notice, you may not be able to reschedule for 8 weeks. If you arrive late for your initial intake appointment, the duration of your appointment may be reduced and/or you may be required to return for another appointment to complete the intake process.

Follow-up appointments can be scheduled by calling the front desk at 608-713-9898, option 2. CSIP does not offer scheduling online or via email/patient portal message.

For follow-up appointments, you must notify CSIP at least 24 hours in advance if you are unable to attend. Outside of normal business hours, notice can be given via confidential voicemail or patient portal message. Exceptions may be made for emergencies or extenuating circumstances, which will be determined on a case-by-case basis.

CSIP strongly recommends arriving at the clinic (or logging on, for telehealth) 15 minutes prior to an appointment’s scheduled start time. If you arrive (or log on) 15 minutes or more past the scheduled start time, your appointment will be marked as a no-show and rescheduled. Patients are required to be located within the state of Wisconsin for all appointments, including those which take place via telehealth.

Despite their best efforts, your provider may be running late for an appointment; this is unavoidable due to CSIP’s commitment to giving each patient the time they need to ensure their concerns are addressed. It is your responsibility as the patient to set aside enough time in your own schedule to see your provider.

Missing 2 or more appointments within a rolling 12-month period puts a patient at risk of discharge from the clinic. CSIP sends warning letters after each missed appointment.

In order to be considered an active patient (eligible to receive prescriptions), patients must attend appointments at the interval recommended by their provider. CSIP is conscientious about the cost of medical care and providers do not request unnecessary appointments. At minimum, clinic policy requires patients to be seen at least once every 6 months. In addition, 1 appointment per rolling 12-month period MUST take place in-person. Providers have the discretion to require appointments, including in-person appointments, at a higher frequency than the clinic minimum. CSIP staff will send a letter to any patient whose last appointment took place 6 or more months ago; failure to respond by the required deadline will result in discharge from services.

Emergency procedures

For life-threatening emergencies, call 911 or go to the nearest emergency department.

CSIP is an outpatient clinic that does not provide emergency services. For psychiatric emergencies after business hours, such as thoughts of suicide or thoughts of harming yourself or others, you may contact the clinic’s after-hours Crisis Line for guidance at 608-579-0144.

Their staff will take a message and relay it to the clinic’s on-call provider, who will follow up with you as needed. The Crisis Line is for urgent matters and should only be used in rare situations that absolutely cannot wait until business hours; during business hours, please do not use the Crisis Line - call the clinic directly.

Questions about scheduling or medication refill requests are NOT considered urgent matters.

Medication issues and concerns that may life-threatening will be directed to emergency or urgent care facilities by the CSIP provider assigned to your case. Inappropriate or excessive use of the after-hours Crisis Line may be grounds for discharge from the clinic.

Missed Appointment Fees

Missed psychiatric intake appointment: $200

Missed psychiatric follow-up appointment: $100

*Please note: if your account reflects an outstanding balance due to one or more missed appointment fees, you may not be able to reschedule until the balance has been paid, or a payment plan has been established.

*State law prevents CSIP from charging a missed appointment fee to a patient with Medicaid coverage. However, missed appointments will still count against the patient’s attendance history.

Medication & prescription refill policies

Incoming refill requests are managed at the clinic during business hours ONLY (from 8:00 a.m. - 4:00 p.m. Monday through Thursday, and from 8:00 a.m. - 12:00 p.m. on Friday). Requests received outside these hours will be reviewed the next business day. Do not use the clinic’s after-hours Crisis Line to request a medication refill.

Providers are typically booked with back-to-back appointments each day. Therefore, medication refills are not sent to the pharmacy until the end of the day after providers are done seeing patients. If you have special circumstances requiring a refill prior to the end of the business day, please inform clinic staff, who will relay the message to your provider. We cannot guarantee that requests for midday refills will be accommodated.

For all non-controlled prescription refills, you must contact your pharmacy. They will transmit the request to us. Please allow up to 3 full business days (72 hours) for medication refill requests to be processed. It is YOUR responsibility to ensure you don’t run out of medication; we recommend submitting refill requests 1 full week before your medication runs out. For updates on the status of your prescription refill, please contact your pharmacy. Requests for updates from clinic staff regarding the status of your refill(s) will NOT be returned.

Medication refills are made at the discretion of your provider and may not be authorized if you are past due for an appointment.

Replacement of lost, misplaced, stolen, or destroyed medication is made at your provider’s discretion. If your medication is stolen, you must provide both CSIP and your dispensing pharmacy with a police report. Since your insurance may not cover an early refill due to loss or theft, your CSIP provider will typically prescribe enough of the medication to last until you would have been due for a refill, and you should anticipate paying out-of-pocket for this replacement medication.

Most prescriptions for non-controlled substances can be transferred from one pharmacy to another. If you need a prescription transferred, please call the pharmacy you would like to use and ask them to transfer the prescription from the original pharmacy. Your CSIP provider can send a new prescription to the new pharmacy, however the clinic’s 72-hour refill waiting period will apply, so making the arrangements yourself saves time.

It is against clinic policy to send prescriptions to pharmacies outside of Wisconsin (with the exception of mail-order pharmacies located out-of-state). If you need to refill a non-controlled prescription while you’re in another state, your provider can send a prescription to a Wisconsin pharmacy with a location near you. You will be responsible for arranging for the transfer of that prescription.

If you are planning a trip outside the United States, it is your responsibility to research whether you are permitted to bring your medication(s) to your destination and confirm what, if any, documentation is required. Any requests for your provider to write a letter or complete documentation facilitating your travel must be discussed during an appointment, and the clinic’s standard 10-day working period for completion of documentation applies, so please plan accordingly.

Policies specific to controlled substances (i.e. stimulants, benzodiazepines, etc.)

For patients who are new to the clinic, or who are being prescribed a controlled substance for the first time, an initial toxicology screening (drug test) is required. Your provider cannot prescribe a controlled substance until they have had a chance to review the results of this toxicology screening. Patients who are established on a controlled substance must complete subsequent toxicology screening on an annual basis at minimum (quarterly for patients receiving suboxone), OR at a frequency to be determined by their provider. If the results of a toxicology screening are inconsistent, your provider may halt the prescription of any controlled substances while you undergo further screening.

Many pharmacies do not allow patients to request refills of controlled substances, such as stimulants. Therefore, as an additional service to our patients, CSIP maintains internal refill reminders that repeat each month roughly 1 week before a medication is due to run out. With these refill reminders in place, you shouldn’t need to manually request refills unless you need the prescription sent to a different pharmacy. Refill reminders do not override existing requirements for a patient to be in “good standing” with the clinic.

Regardless of when their last appointment took place, patients are required to have a future appointment on the calendar in order to be eligible for refills of controlled substances. Attendance patterns are monitored, and if you miss scheduled appointments frequently, your provider may only allow you to request refills during appointments.

Prescriptions for controlled substances cannot be transferred from one pharmacy to another. If you need to fill your prescription at a different pharmacy from where it was originally sent, please contact the clinic. Staff will cancel the original prescription and prepare a new prescription for your provider’s review and signature. The clinic’s 72-hour refill waiting period will apply to this new prescription.

It is against clinic policy to send prescriptions to pharmacies outside of Wisconsin (with the exception of mail-order pharmacies located out-of-state), and since prescriptions for controlled substances cannot be transferred from one pharmacy to another, we are unfortunately not able to accommodate out-of-state requests for controlled substances.

Correspondence with the clinic

NOTE: unless arrangements are made in advance, providers are NOT available for direct phone calls, and all discussions must take place during a scheduled appointment.

Office staff are available to answer the phone and monitor patient portal messages on weekdays between 8:00 a.m. and 4:00 p.m. (until 2:00 p.m. on Fridays). The clinic is fully closed on weekends. Holiday closures are announced in advance via the main voicemail greeting. If staff are unavailable to take your call live, please leave a detailed message on the appropriate line with your name, phone number, and a detailed message. Voicemails and patient portal messages are routinely checked during business hours, and staff will triage concerns to providers as appropriate. Your provider will review the message and instruct staff on how to address your question or concern. Calling the office multiple times or sending multiple patient portal messages will NOT expedite your request in any way. Office staff can only respond to voicemail messages, not missed calls without a message.

Patients cannot speak directly with their provider when calling or messaging the clinic. All calls and messages are first routed through front desk staff or patient care coordinators. Please be prepared to dictate your message to patient care staff and wait for a response. Providers do their best to provide guidance within 24 hours of receiving a message. If a provider is out of the office, there may be a delay while staff await their return, OR your concern may be addressed by a provider you don’t typically meet with.

Please note that requests for medication changes over the phone or via patient portal message (including new prescriptions OR modifications to existing prescriptions) will NOT be granted. Medications are best managed during appointments, therefore patient care staff will assist you in scheduling an appointment to meet with your provider.

If your matter is urgent and you cannot wait 1-3 business days for a response, please call 911 or go to your nearest emergency department or urgent care facility.

CSIP communicates with patients via phone, patient portal message, email, and mail. Patients are responsible for ensuring that their contact information is up-to-date at all times. CSIP strongly recommends setting up your voicemail inbox and ensuring there is adequate space for new messages, as well as frequently checking for patient portal messages or letters, to avoid missing important correspondence from the clinic.

Requests for documentation

If you are in need of a medical form and/or a letter from your provider regarding confirmation of care, recommendation or referral, diagnosis or treatment information, or any other documentation, you must schedule an appointment with your provider so they can review and discuss your request. Please be aware that your provider may not be able to accommodate all requests, and that some documentation is handled on a case-by-case basis. Following the appointment where your request was discussed, providers require a minimum of 10 business days to complete documentation. Please be sure to plan accordingly. We require your written authorization to release medical information to any third parties, and there may be a fee assessed for letters, form completion, or copies of your records.

Students and Interns

Your provider may have a scribe attending appointments remotely for the purpose of charting and documentation.

CSIP is a teaching clinic, and as such your provider will often have a Nurse Practitioner or Physician Assistant student observing appointments or working directly with patients as part of their clinical rotation.

Telemedicine

Telehealth links are sent out via email and text message 72 hours prior to the appointment’s scheduled start time. We strongly encourage patients to log on 15 minutes prior to the scheduled start time. If you are having issues logging on, or if you have been waiting for your provider for more than 5 minutes past the scheduled start time, please call 608-713-9898 and select option 4 for assistance from clinic staff.

If you enter the virtual waiting room 15 minutes or more past the scheduled start time, your appointment will be marked as a no-show and rescheduled.

Involuntary discharge policy

The following is a non-exhaustive list of examples of reasons for a patient’s involuntary discharge from services at Collaborative Solutions in Psychiatry. Patients who have been discharged from the clinic are no longer eligible to receive prescription medications beyond a final 30-day fill provided at the provider’s discretion (final refills of controlled substances are typically NOT provided). Patients who have been discharged from the clinic due to non-compliance with clinic policy are not eligible for reinstatement at any point in the future.

Failure to adhere to the appointment attendance / cancellation policies
Noncompliance with treatment recommendations
Disruptive or inappropriate behavior toward providers, staff, and/or other patients
Inability or failure to pay for services (including copays and coinsurance)
Withholding pertinent information about care or prescriptions you receive from other providers
Requiring care beyond what CSIP is able to provide

Payment

Payment is expected on the day services are received. This applies to co-payments, payments towards deductibles, or out-of-pocket payments.

You may be unable to see your provider until your balance is paid in full, or a payment plan has been established.

Texting Terms of Service

1. Collaborative Solutions in Psychiatry, SC (CSIP) offers access to messaging services via SMS (Short Message Service) and MMS (Multimedia Message Service) text alerts (the “Program”). Please read these terms of Service carefully before participating in the Program. By opting into and participating in the Program, you are agreeing to these Terms and Conditions and these Terms of Service and Privacy Policy https://www.csipmadison.com/policies as well. If you do not agree to these Terms of Service and Privacy Policy, you cannot participate in the Program.

Text alerts sent under the Program may include or be similar to:

Welcome messages,
patient registration coordination,
paperwork notifications,
when CSIP needs to contact you about services it is coordinating for you,
appointment scheduling and coordination of,
financial billing and insurance coordination,
other services that CSIP may offer.

2. When you opt-in to the service, we will send you an SMS message to confirm your signup.

3. How often CSIP messages you will depend on your engagement with our clinic and your individual needs.

4. You can cancel the Program service at any time. Just text "STOP" to any of our messages. After you send the SMS message "STOP" to us, we will send you an SMS message to confirm that you have been unsubscribed. After this, you will no longer receive SMS messages from us. If you want to join again, just sign up as you did the first time and we will start sending SMS messages to you again.

5. Message and data rates may apply for any messages sent to you from us and to us from you. Message frequency varies. If you have any questions about your text plan or data plan, it is best to contact your wireless provider.

6. If you are experiencing issues with the Program you can reply with the keyword “HELP” for more assistance, or you can get help directly at 608-713-9898 or at moreinfo@csipmadison.com.

Privacy Policy

HIPAA 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.

About This Notice

This notice describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

We are required by law to maintain the privacy of your protected health information; give you this notice of our legal duties and privacy practices with respect to your protected health information; and follow the terms of our notice that are currently in effect. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at the time as well as any information we may receive in the future. You can obtain any revised Notice of Privacy Practices by contacting our office.

How We May Use and Disclose Your Protected Health Information

The following examples describe different ways that we may use and disclose your protected health information. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. We are permitted to use and disclose your protected health information for the following purposes. However, our office may never have reason to make some of these disclosures.

For Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your health care treatment and any related services. We may also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time to time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

For Payment

Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to your health plan to obtain approval for hospital admission.

For Health Care Operations

We may use and disclose your protected health information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and for our operation and management purposes. For example, we may use your protected health information to review the treatment and services you receive to check on the performance of our staff in caring for you. We also may disclose information to doctors, nurses, technicians, medical students, and other personnel for educational and learning purposes. The entities and individuals covered by this notice also may share information with each other for purposes of our joint health care operations.

Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services

We may use and disclose your protected health information to contact you to remind you that you have an appointment for treatment or medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.

Fundraising Activities

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our office and request that these fundraising materials not be sent to you.

Plan Sponsors

If your coverage is through an employer sponsored group health plan, we may share protected health information with your plan sponsor.

Facility Directories

Unless you object, we may use and disclose in our facility directory your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Others Involved in Your Healthcare

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Required by Law

We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health

We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury, or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Business Associates

We may disclose your protected health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Communicable Diseases

We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight

We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

Abuse or Neglect

We may disclose your protected health information to a public health authority this is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration

We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required by law.

Legal Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful process.

Law Enforcement

We may also disclose your protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation

We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.

Research

We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity

Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose your protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security

When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits; or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation

Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates

We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

For Data Breach Notification Purposes

We may use or disclose your protected health information to provide legally required notices of unauthorized acquisition, access, or disclosure of your health information. WE may send notice directly to you or provide notice to the sponsor of your plan, if applicable, through which you receive coverage.

Required Uses and Disclosures

Under the law, we must make disclosures to you and when required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

Special Protections for HIV, Alcohol and Substance Abuse, Mental Health, and Genetic Information

Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. For example, a health plan is not permitted to use or disclose genetic information for underwriting purposes. Some parts of this Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact our office for more information about these protections.

Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization

Uses and disclosures of your protected health information that involve the release of psychotherapy notes (if any), marketing, sale of your protected health information, or other uses or disclosures not described in this notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization at any time, in writing, except to the extent that this office has taken an action in reliance on the use or disclosure indicated in this authorization. Additionally, if a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, it is our intent to meet the requirements of the more stringent law.

Your Rights Regarding Health Information About You

The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of your protected health information that is contained in your designated file for as long as we maintain the protected health information. A “designated file” contains medical and billing records and any other records that your physician and the office uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You must make a written request to inspect and copy your designated file. We may charge a reasonable fee for any copies.

Additionally, if we maintain an electronic health record of your designated file, you have the right to request that we send a copy of your protected health information in an electronic format to you or to a third party that you identify. We may charge a reasonable fee for sending the electronic copy of your protected health information.

Depending on the circumstances, we may deny your request to inspect and/or copy your protected health information. A decision to deny access may be reviewable. Please contact our office if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

This office is not required to agree to a restriction unless you are asking us to restrict the use or disclosure of your protected health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you paid us out-of-pocket in full. If this office believes it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted. If this office does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by contacting our office.

You have the right to restrict information given to your third party payer if you fully pay for the services out of your pocket. If you pay in full for services out of your own pocket, you can request that the information regarding the services not be disclosed to your third party payer since no claim is being made against the third party payer.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our office.

You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in your designated file for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our office if you have questions about amending your medical record. Your request must be in writing and provide the reasons for the requested amendment.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limitations. Additionally, limitations are different for electronic health records.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

You have the right to receive notice of a security breach. We are required to notify you if your protected health information has been breached. The notification will occur by first class mail within 60 days of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that comprises the privacy or security of your protected health information. The notice will contain the following information: (1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach; (2) the steps you should take to protect yourself from potential harm resulting from the breach; and (3) a brief description of what we are doing to investigate the breach, mitigate losses, and to protect against further breaches.

Complaints or Questions

You may complain to us or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a written complaint with us by notifying our office of your complaint. We will not retaliate against you for filing a complaint. You may reach our office by calling: 608-713-9898. If you have a question about this privacy notice, please contact our Privacy Officer at: 608-713-9898, extension 7.

Effective date: This notice is effective as of 9/23/2013.