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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:
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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. |
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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.
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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. |
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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.
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Disclosures required by Law:
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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. |
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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. |
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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: |
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Request a restriction
on certain uses and releases of your information. |
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Obtain a paper copy of
the notice of information practices. |
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Inspect a copy of your
health record. |
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Amend your health record
as provided in 45 CFR 164.528. |
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Request communication
of your health information by alternative means or at another location.
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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: |
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Maintain the privacy of
your health information. |
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Provide you with a notice
as to AMS's legal duties and privacy practices with respect to information
AMS collects and maintains about you. |
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Abide by
the terms of this notice. |
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Notify you is AMS is unable
to agree to a requested restriction. |
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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
Ann Olson, AMS's 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.
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Affiliated Medical Services
1428 N. Farwell Avenue, Milwaukee, WI 53202
(800) 498-0424 | (414) 278-0424
 
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