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. Affiliated Medical Services ("AMS") is committed to protecting the privacy of your health record and the confidentiality of your visit. Your healthcare record, know as a chart, and the information it contains will not be disclosed to any one or any agency outside of AMS without written authorization from you unless such a release is required by law.
AMS will use your health information for the purpose of:
• Treatment: For example, information obtained by a healthcare provider or staff member will be recorded in your record and used to determine the e best course of treatment for you.
• Payment: For example, a bill may be sent to you or to a third party payer. The information on the bill may include information that identifies you, as well as your diagnosis, procedure and the supplies used.
• Regular Healthcare Operations: For example, a member of the medical staff or the quality improvement / risk management staff may use the information in your health record to access the care you received and the outcomes of your care. This information will then be used in the Continuous Quality Improvement program of AMS.
• Business Associates: AMS provides some services through contractors with business associates. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Disclosures required by Law:
• Food and Drug Administration (FDA): As required by law, AMS may disclose to the FDA health information relative to adverse events with respect to product defect, product recall,repairs or replacement.
• Public Health: AMS may disclose your health information, as required by law, to public health or legal authorities charged with preventing or controlling disease, injury or disability.
• Law Enforcement: AMS may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. You're Health Information Rights Although your record is the property of AMS, the information it contains belongs to you.
You have the right to:
• Request a restriction on certain uses and releases of your information.
• Obtain a paper copy of the notice of information practices.
• Inspect a copy of your health record.
• Amend your health record as provided in 45 CFR 164.528.
Request communication of your health information by alternative means or at another location.
Revoke your authorization to use or disclose health information except to the extent that disclosure has already take place.
Our Responsibility AMS is required to:
• Maintain the privacy of your health information.
• Provide you with a notice as to AMS's legal duties and privacy practices with respect to information AMS collects and maintains about you.
• Abide by the terms of this notice.
• Notify you is AMS is unable to agree to a requested restriction.
• Accommodate reasonable requests you any have to communicate health information by alternative means or at alternative locations.
AMS reserves the right to change practices and to make the new provisions effective for all protected health information AMS maintains. Should AMS's information practices change, we will make reasonable effort to notify you of this change at your next visit. For More Information or to Report a Problem If you have questions, or if you want to report a problem, please contact our Privacy Officer, at (414) 278-0424.
Complaints may also be filed with the United States Secretary of Health and Human Services, an act for which no retaliation will occur. You will be asked to sign a form indicating that you have read this statement. Prior to signing the form, be sure to ask any questions that you have regarding the information it contains.
Affiliated Medical Services will hold your record to the highest standard of privacy and confidentiality, and will only release personal health information when authorized in writing or when required by law.
"I came alone, frightened, and extremely nervous. However, each and every one of you, from the front desk to the recovery room, helped ease that anxiety. You all showed concern and friendliness, and were quite informative. Dr. Smith was professional yet pleasant, which meant so much to me. I was not alone after all. I had the support of all of you."