Privacy Practices Notice

THIS NOTICE DESCRIBES HOW PROTECTED MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. MDI is permitted to make uses and disclosures of protected health information for treatment, payment and health care operations, as described in the following examples:
   a. For treatment - MDI will contact you to provide appointment reminders. Your report will be faxed to your physician's office, and any other physician that you authorize us to send your report to.
   
   
   b. For payment - To obtain preauthorization of services and reimbursement for services rendered, information provided by both you and your referring physician's office, including demographic information, final exam report, medical history, and insurance information will be mailed to MDI's billing/claims processing center (Per-se Technologies).
   
   
   c. For health care operations - Your medical record could be reviewed by an accreditation or certification committee to allow accreditation of medical equipment and/or Lab proficiency testing and procedures. It could also be reviewed for annual billing audits for billing compliance analysis.
   
   
2. MDI is permitted or required, under specific circumstances, to use or disclose protected health information without the individual's written authorization for disclosures to:
   a. The individual to whom the PHI applies.
   
   b. The Secretary of Health and Human Services.
   
   c. Public or law enforcement agencies: Under circumstances specified in the Privacy Regulation.
   
   
3. Other uses and disclosures will be made only with the Individual's written authorization, and the individual may revoke such authorization.
   
   
4. MDI intends to engage in the following activity:
   a. MDI may contact the individual to provide appointment reminders or information about treatment alternatives or other heath-related benefits and services that may be of interest to the individual or patient.
   
   
5. The Individual has the following rights regarding protected health information:
   a. The right to request restrictions on certain uses and disclosures of protected health information. MDI is not required to agree to a requested restriction, however.
   
   b. The right to receive confidential communications of protected health information, as applicable.
   
   c. The right to inspect and copy protected health information, as provided in the Privacy Regulation.
   
   d. The right to amend protected health information, as provided in the Privacy Regulation.
   
   e. The right to receive an accounting of disclosures of protected health information.
   
   f. The right to obtain a paper copy of the Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the Notice electronically.
   
   
6. MDI is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and Privacy practices with respect to protected health information.
   
   
7. MDI is required to abide by the terms of the Notice currently in effect.
   
   
8. MDI reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains.
   
   
9. MDI will provide individuals or patients with a revised Notice by displaying the new Notice at the front desk area with the revised date documentation.
   
   
10. Individuals may complain to MDI and to the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. If you have a complaint that you would like to file, you may ask the front desk reception staff for a complaint form. Please fill out this form and place in the envelop provided. Return form to MDI.
    
    
11. MDI's contact person(s) for matters relating to complaints are:
    Carol Martin - Executive Director
    Linda Kuspa - Manager
    Pat Gruenwald - Manager
    Greenfield:
    Tele# 414-282-4100
    6150 W. Layton
    Greenfield, WI 53220
    
    OR
    
    Franklin:
    Tele# 414-325-4300
    3111 W. Rawson
    Franklin, WI 53132
    
    
12. This Notice is first in effect on March 26, 2003.