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.

This notice describes the medical information practices of Midwest Open MRI, LLC and that of any third party that receives medical information from or for us to assist us in providing services to you.

Midwest Open MRI may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability (HIPAA) Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations.  Midwest Open MRI has established a policy to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. We may use your health information to provide care to you and disclose your health information to others who provide care to you. For example, physicians involved in your care will need information about imaging services provided you in order to recommend proper treatment options.

To Obtain Payment. We may include your health information in invoices to collect payment from third parties for the services your received from Midwest Open MRI. For example, we may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Midwest Open MRI. We may also need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you.

To Conduct Health Care Operations. We may use your health information for certain operational, administrative and quality assurance activities. This information may be used in an effort to continually improve the quality and effectiveness of the service we provide. We may disclose information to business associates if they need to receive this information to provide a service to us and will agree to abide by specific HIPAA rules relating to the protection of health information. Midwest Open MRI is permitted to use or disclose your PHI for the following purposes; however, we may never have reason to make some of these disclosures.

Communicate with Individuals Involved in Your Care or Payment For Your Care. We may disclose to a family member, other relative, close personal friend or any other person you identify, PHI directly relevant to that person’s involvement in your care or payment related to your care.

When Legally Required. We will disclose your health information when it is required to do so by any Federal, State or local law.

Risks to Public Health. We may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Conduct Health Oversight Activities. We may disclose your health information to a health oversight agency for activities including: audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action.

Law Enforcement Purposes. As permitted or required by State law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

Worker’s Compensation. We may release your health information for workers’s compensation or similar programs.

Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION:

Other than is stated above, Midwest Open MRI will not disclose your health information other than with your written authorization. If you or your representative authorizes us to use or disclose your health information, you may revoke that authorization in writing at any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION:

You have the following rights regarding your health information that Midwest Open MRI maintains:

Right to Request Restrictions. You may request restrictions on certain uses and disclosures for your health information. You have the right to request a limit on our disclosures of your health information to someone who is involved in your care or the payment of your care. However, we are not required to agree to your request.

Right to Receive Confidential Communications. You have the right to request that we communicate with you in a certain way. For example, you may ask that we only conduct communications pertaining to your health information with you privately with no other family members present.

Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information, including billing records. If you request a copy of your health information, we may charge a reasonable fee for copying and assembling and mailing requested information.

Right to Amend Your Health Information. You or your representative have the right to request that we amend your records if you believe your information is incorrect or incomplete. You must send a written request to us and include a reason that supports your request.

Right to an Accounting. You or your representative have the right to request an accounting of disclosures of your health information made by us for certain purposes authorized by law and certain research. Your request must specify the time period, may not be longer than six years, and may not include dates prior to April 14, 2003.

Right to a Paper Copy of this Notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously.

DUTIES OF PROVIDER:

Midwest Open MRI is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. We are required to abide by the terms of this Notice as may be amended from time to time. We reserve the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If we make a material change to this Notice, we will provide a copy of the revised Notice to you. You have the right to express complaints to Midwest Open MRI and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated.

EFFECTIVE DATE: This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:

Privacy Officer
Midwest Open MRI
2101 Zeier Road
Madison, WI 53704
608-663-6674