Dubuque Internal Medicine, P.C
1515 Delhi Street, Suite #100
Dubuque, IA 52001
563-557-9111

NOTICE OF PRIVACY PRACTICES

Effective April 14, 2003

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.

Dubuque Internal Medicine, P.C. has always respected our patients’ right to privacy and our office has always been committed to assuring the confidentiality of your health care information. All the physicians and authorized staff at Dubuque Internal Medicine, P.C. (including all Tri-State Dialysis facilities) have access to your medical record and may use and disclose your health care information as outlined in this notice.

A list of the locations covered by this notice is attached to the end of this document.

Dubuque Internal Medicine, P.C. reserves the right to change this Notice of Privacy Practices without any additional notice to you. Nevertheless, upon your request, you can receive a copy of our revised Notice of Privacy Practices. In addition, any changes will be posted prominently in our office as well as on our web site at Any revisions made to this Notice of Privacy Practices will apply to ALL of your medical information, regardless of whether the medical record information was created before or after the effective date of any revised Notice of Privacy Practices.

PRIVACY CONTACT:

If you have questions about any information in this policy, please contact the Privacy Officer at Dubuque Internal Medicine, P.C. at 563-557-9111.

DEFINITION OF TERMS:

Throughout this document, we use the terms "use" and "disclosure" of health information. "Use" refers to how health information is utilized within our office by physicians and employees of Dubuque Internal Medicine, P.C. "Disclosure" refers to your health information that is provided to someone outside of Dubuque Internal Medicine, P.C.

USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION:

There are certain activities that involve using and disclosing your protected health information (PHI) that do NOT require your written authorization. Below, we list these activities. In addition, we also provide some examples in each category in order to clarify the nature of these activities. These examples are NOT meant to describe every use and disclosure for each activity. Activities NOT requiring a written authorization include:

TREATMENT:

Your PHI will be used to provide, coordinate and manage your health care treatment. For example, if we refer you to an orthopedic surgeon, we will share your PHI with that physician’s office.

PAYMENT:

Your PHI may be used in order to receive payment for the health care services you receive in or through our office. For example, your health insurance company may request your physician’s office notes in order to determine if the service provided is a covered benefit under your health plan. Some health plans do not pay for preventive services or services not directly involved in the treatment of a specific disease or illness. Furthermore, your PHI may be shared with the guarantor of your health insurance.

HEALTH CARE
OPERATIONS:

We may use or disclose your protected health information for certain activities performed by our office that support the business and professional activities at Dubuque Internal Medicine, P.C. These activities include, but are not limited to, quality assessment activities, training of medical students and Internal Medicine residents, licensing and conducting and arranging for other business activities.

For example, we may use your health information in our quality assurance reviews. Also, we may need to release health care information to consultants, attorneys and accountants to make sure we are compliant with the many laws and regulations that affect our organization.

We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) for our office. Whenever an arrangement between our office and a "business associate" involves the use or disclosure of protected health information, we will have a written contract with the business associate that contains terms that will protect the privacy of your health information.

APPOINTMENT
REMINDERS:

Unless you tell us otherwise, in writing, we may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

DISEASE
MANAGEMENT:

On occasion, we may use protected health information to identify patients with certain illnesses or conditions so that we may provide information to you about treatment alternatives or other information related to your condition. You may contact our Privacy Contact (listed at the beginning of this notice) if you do not want to receive this information.

Other permitted and required uses and disclosures that may be made without your consent, authorization or opportunity to object:

We may use or disclose your protected health information in the following situations WITHOUT your consent or authorization. These situations include:

  1. Public health information (for the purpose of controlling disease, injury or disability),
  2. Communicable disease reporting (if authorized by law, we will disclose communicable disease information to an exposed person, who may be at risk of spreading or contracting a certain disease),
  3. Health oversight agencies (for example, we may be asked to release PHI to a government agency charged with auditing, investigating or inspecting health care providers),
  4. Abuse or neglect (for example, we may be required to disclose your protected health information if we believe you are the victim of abuse, neglect or domestic violence),
  5. Food and Drug Administration (for example, we may be required to disclose your protected health information when reporting an adverse outcome to a prescription drug),
  6. Certain legal proceedings (for example, the court may order us to disclose your protected health information and we will comply with any valid court order),
  7. Law enforcement (under certain limited circumstances),
  8. Organ or tissue donations (we use and disclose PHI to facilitate these donations),
  9. Coroners and funeral directors (we only disclose that PHI that is required by law),
  10. Research (we may disclose your PHI to researchers when the research has been approved by an institutional review board and has an established protocol to ensure the privacy of your PHI),
  11. Criminal activity (we may disclose your PHI 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),
  12. Military activity/National security,
  13. Worker’s compensation,
  14. Inmates (This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others or for the safety and security of the correctional institution),
  15. Other required uses and disclosures (Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance to Section 164.500 et. seq.)
  16. Marketing: Dubuque Internal Medicine does not use or disclose PHI for marketing purposes.

All of the above information simply explains how your protected health information is used and disclosed by our office. If you object to any of the above provisions, you can request changes, restrictions or exceptions to the above guidelines. We are not required to accommodate your request to restrict use or disclosure of your protected health information as it relates to the areas of treatment, payment or health care operations. Your request for a restriction in the use and disclosure of your protected health information must be IN WRITING and sent to the Privacy Officer at:

 

Privacy Officer

Dubuque Internal Medicine, P.C.

1515 Delhi Street, Suite #100

Dubuque, IA 52001-6389

Other permitted uses and disclosures of your protected health information that may be made without authorization

Others involved in your health care: Unless you object, we may disclose your protected health information to a family member, relative, close friend or anyone else you identify. We will only reveal that portion of 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 your protected health information to such persons if we determine that it is in your best interest based on our professional judgement. The practice does not disclose protected health information to a suspected abuser, if there is reason to believe that such a disclosure could cause the patient serious harm. Also, we may disclose medical information about you to an entity assisting in a disaster relief effort so that they can notify your family about your condition, status and location.

Emergencies: We may disclose your protected health information in an emergency treatment situation.

Communication Barriers: We may use or disclose your protected health information without your consent due to substantial communication barriers and if the physician determines that you intend to consent to use or disclose protected health information.

Uses and Disclosures of Protected Health Information based upon your written authorization

As of the effective date of this Notice, your health information will be used and disclosed as outlined in this policy without any need for any additional authorization from you. Any and all other uses of your PHI will be made only with your written authorization. You may revoke this authorization, at any time, in writing, except to the extent that our office has already taken action in accordance with the authorization. In Iowa, a specific written authorization is required to disclose or release mental health treatment records, substance abuse (alcohol and drug) treatment records and HIV/AIDS information.

YOUR RIGHTS:

  1. You have the right to inspect and copy your protected health information. Under federal law, you may NOT inspect the following records:
    1. Psychotherapy notes.
    2. Information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action.
    3. Any protected health information that the law prohibits your access.

Your request to inspect and copy your PHI must be in writing and addressed to:

Medical Records Copying Coordinator, Dubuque Internal Medicine, P.C., 1515 Delhi Street, Suite #100, Dubuque, IA 52001.

 

Dubuque Internal Medicine reviews the request in a timely fashion and acts on the request for access, generally within 30 days. If necessary, we may need an additional 30 days to act on the request. Each request is either accepted or denied and the requestor will be notified in writing. If a request is denied, the requestor will be informed if the denial is "reviewable" or not. The requestor has the right to have any denial reviewed by a licensed health care professional at Dubuque Internal Medicine who did not participate in the original decision to deny access. Dubuque Internal Medicine informs the requestor of the decision of the reviewing professional and adheres to that decision.

Depending on the circumstances, a decision to deny access to your protected health information may be subject to review. Please contact our Medical Records Copying Coordinator if you have any questions about access to your medical record.

If you request to inspect and/or copy of your PHI, we may charge you a reasonable fee based on the actual cost of fulfilling your request. If the requestor agrees to pay the fee in advance, the records will be provided. Otherwise, unless the Privacy Officer determines the charge is burdensome to the requestor, the records will not be provided.

  1. You have the right to request a restriction in the use and disclosure of your protected health information. Your request must be in writing and must state the specific restriction requested and to whom you want the restriction to apply. Your request needs to be directed to the privacy officer. We are not required to agree to the restriction you request. If your physician believes that it is in your best interest to permit the use and disclosure of protected health information, your protected health information will not be restricted. If your physician does agree to the restriction, our office will honor the restriction unless the protected health information is needed to provide emergency treatment.
  1. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. Please make these requests in writing to the privacy contact listed on the first page of this "Notice of Privacy Practices." The request must specify an alternative address or other method of contact and must contain information about how payment will be handled. A reason for your request for alternative means to receive confidential communications is NOT required. Dubuque Internal Medicine accommodates all reasonable requests to keep communications confidential. The practice determines the reasonableness based on the administrative difficulty of complying with the request.
  1. You have the right to have your physician amend your protected health information. If you feel that the medical information in your record is incorrect or incomplete, you may request an amendment of your protected health information. Your request must be in writing and sent to the Privacy Officer at Dubuque Internal Medicine. Your request must provide the reason for your request. We will respond to your request in a timely manner, usually within 60 days after receipt of such request. If we need more time, we will notify you within the 60 day time frame of the need for an extension, and will provide you with a reason for the delay and also provide a date by which the practice will complete the request (no more than 30 additional days). We have the right to deny your request. We may deny your request because the information was not created by us (unless the person who created the information is no longer available to make an amendment) or because the information is not part of your designated record set, or if we believe the information is complete and accurate. If we deny your request, we will notify you in writing and you have the right to file a statement of disagreement with us. Your statement of disagreement must include the basis of the disagreement. We limit your statement of disagreement to one page. We may prepare a rebuttal to your statement and we will provide you with a copy of any such rebuttal.
  1. You have the right to receive an accounting of certain disclosures we have made of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations. It also excludes disclosures we have made to you, to your family members and friends involved in your health care or for notification purposes (National security or intelligence purposes or to correctional institutions or law enforcement officials). It also excludes any disclosures made pursuant to your written authorization. This accounting will only cover disclosures made after the effective date of this notice. To request this list, you need to submit your request in writing to: Medical Records Copying Coordinator, Dubuque Internal Medicine, P.C., 1515 Delhi Street, Suite #100, Dubuque, IA 52001. Your request must state a time period of up to 6 years prior to the request. Shorter time periods are allowed. However, patients may only request an accounting of disclosures made on or after April 14, 2003. The practice allows an individual to request one accounting within a 12 month period free of charge. Any additional requests will be charged a reasonable fee. The practice responds to all requests for an accounting of disclosures within 60 days of receipt of the request. If we are unable to accommodate your request, we will notify the requestor of such and the reason for the delay and the date the request is expected to be fulfilled. Only one 30 day extension is allowed.
  1. You have the right to obtain a paper copy of this notice from us.

COMPLAINTS:

If you believe that your privacy rights have been violated by us, you can notify us directly with your concerns. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

All complaints must be in writing, must describe the acts or omissions that are the subject of the complaint, must be filed within 180 days of the time when you (the patient) became aware or should have been aware of the violation. Complaints must be addressed to:

Privacy Officer

Dubuque Internal Medicine, P.C.

1515 Delhi Street, Suite #100

Dubuque, IA 52001-6389

All complaints will be investigated and we may, at our discretion, reply to the patient or the patient’s agent. Alternatively, if you are not satisfied with our response to your concern, you can contact the Secretary of the Department of Health and Human Services directly.

LOCATIONS COVERED BY THIS NOTICE OF PRIVACY PRACTICES:

Dubuque Internal Medicine, P.C.
1515 Delhi Street, Suite #100
Dubuque, IA 52001

Dubuque Internal Medicine, P.C.
1500 Delhi Street, Suite #2100
Dubuque, IA 52001

Tri-State Dialysis
Delhi Medical Center
1500 Delhi Street, Suite #2100
Dubuque, IA 52001

Tri-State Dialysis
Second and Main
Guttenberg, IA 52052

Tri-State Dialysis
709 West Main
Manchester, IA 52057

Tri-State Dialysis
1250 East Highway 151
Platteville, WI 53818