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HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION 

We may use your health information and disclose it to appropriate persons, 
authorities and agencies, as allowed by federal and state law. We may do this 
without your written permission for the following purposes: 

Treatment. As we treat you, we may need to use and disclose your health 
information to other health care providers within or outside of LMC. For 
example, a doctor may use the information in your medical record to find the 
best treatment option for you or a pharmacist may call your doctor to ask 
questions about a prescription. In some cases, our staff may use or disclose your 
health information to help your doctor and our health care team manage your 
disease. 

Payment. We may use your health information and disclose it to insurance 
companies or employer health plans, and to others in order to receive payment 
for your bill. For example, we must submit a bill to your insurance company that 
states your name, what is wrong with you, how we are treating you, and other 
information in order for us to receive payment. In certain situations, we may 
disclose your health information to a collection agency if a bill is not paid. 

Health Care Operations. We may use the information in your medical record to 
help us improve the quality or cost of the care we give or to respond to 
appropriate questions about the care provided. For example, we may study how 
doctors and nursing staff manage patient treatment. We may use your health 
information to look at the care you received from doctors, nursing staff, or other 
health care professionals. We may disclose your health information to another 
health care professional that you have seen so they may improve their quality or 
cost. 

Reminders and Information Sharing. We may use your health information to 
remind you of an appointment or to tell you about treatment options or health 
products and services that may be of interest to you. For example, we may send 
you a letter telling you about a new health care facility that is opening in your 
area. 

OTHER WAYS WE MAY DISCLOSE YOUR HEALTH INFORMATION 

We may also use and disclose your health information without your written 
permission for the following purposes: 

Family and Friends for Care and Payment. Unless you request otherwise and in 
emergency situations, we may disclose information to your family members, 
relatives, close friends, or others who are helping care for you or helping you 
pay your medical bills. For example, we may tell these persons where you are 
and how you are doing. 

Disaster Relief Efforts. We may disclose your health information to organizations 
for the purpose of disaster relief efforts. 

Required by Law. We may disclose your health information when required by 
law to do so. 

Public Health. We may disclose your health information to authorities to help 
prevent or control disease, injury, or disability. For example, we are required to 
report certain diseases (for example, cancer), injuries, birth or death information, 
and information of concern to the Food and Drug Administration (FDA) and the 
State of Wisconsin. We may also report work-related illnesses and injuries to 
your employer for workplace safety purposes. 

Reporting Victims of Abuse or Neglect. We may disclose your health 
information, if we believe you have been a victim of abuse or neglect, to a 
government authority if required or allowed by law, or if you agree to the 
disclosure. 

Health Care Oversight. We may disclose your health information to authorities 
and agencies for oversight activities allowed by law, including audits, 
investigations, inspections, licensing, disciplinary actions, or legal proceedings. 
These activities are necessary for oversight of the health care system, 
government programs and civil rights laws. 

Legal Proceedings. We may disclose your health information in the course of 
certain legal proceedings. For example, we may disclose your information in 
response to a court order. 

Law Enforcement. We may disclose your health information to law enforcement 
officials for specific purposes. For example, we may disclose your health 
information when required by law to report certain injuries. 

Death. We may disclose your health information to coroners, medical examiners 
(for example, to find out the cause of death) and funeral directors so they can 
carry out their duties. 

Organ, Eye, or Tissue Donation. We may disclose information to people involved 
in obtaining, storing or transplanting donated organs, eyes or tissue. 

Research. We may disclose your health information to researchers who have 
received approval from LMC to conduct a specific research project. These 
researchers agree not to disclose information that would allow you to be 
identified, except as allowed by law. For example, a research study may measure 
the success of a treatment or medication in treating or curing a targeted illness 
or condition. 

Serious Threats to Health or Safety. We may disclose your health information to 
the proper authorities if we believe in good faith that this will help prevent or 
lessen a serious threat to your or the public’s health or safety. We do so as 
allowed by law and standards of ethical conduct. 

Military, National Security, Law Enforcement Custody. We may disclose your 
health information to the proper authorities so they may carry out their duties 
under the law. This applies if you are or were involved with the military, national 
security or intelligence activities. It also applies if you are in the custody of law 
enforcement officials or an inmate in a correctional institution. 

Workers’ Compensation. We may disclose your information in order to comply 
with the laws related to workers’ compensation or similar programs. These 
programs may provide benefits for work-related injuries or illness. 

We may use or disclose your information only with your written permission, except 
as described in the previous sections. If you give us your permission, you may 
withdraw such permission at any time by notifying us in writing, except if we have 
already taken action based upon your permission. 

A NOTE ON OTHER RESTRICTIONS 

Please be aware that state and federal law may have more requirements than 
HIPAA on how we use and disclose your health information. If there are specific 
more restrictive requirements, even for some of the purposes listed above, we 
may not disclose your health information without your written permission as 
required by such laws. For example, we will not disclose your HIV test results 
without obtaining your written permission, except as permitted by state law. 
We may also be required by law to obtain your written permission to use and 
disclose your information related to treatment for a mental illness, 
developmental disability, or alcohol or drug abuse. 

There maybe other restrictions on how we use and disclose your health 
information than those listed above. We believe state and federal laws 
discussing such restrictions are Wisconsin Statutes Sections 146.82, 51.30, 
252.15, 895.50 and 905.04; Wisconsin Administrative Code HFS 92 and 124.14; 
and 42 C.F.R. Part 2 and 45 C.F.R. Parts 160 and 164. For the most current 
statutes visit; Federal Register at http://www.archives.gov/federal-register/ and 
Wisconsin State Laws at http://wsll.state.wi.us/ 

YOUR HEALTH INFORMATION RIGHTS 

As a patient or customer who receives health care services from LMC, you have 
the right to: 

Read and copy your health information. With a few exceptions, you have the 
right to read and obtain a copy of your health information. We may charge you 
a reasonable fee if you want a copy of your health information. If we deny your 
request to review or obtain a copy, you may submit a written request for a 
review of that decision. 
• To obtain your health information, contact the Medical Records Department of the clinic    where you were treated. 
• To obtain your billing information, contact the Central Business Office at 414-768-1845. 

Request to correct your health information. If you believe there is an error in 
your health information or something has been left out, you may ask us to correct the information. You must make the request in writing and give the reason why your health information should be changed. If we did not create the information you believe is incorrect, or if we disagree with you and believe your health information is correct, we will deny your request. You may appeal to us in writing if we deny your request. 
• To request a correction to your health information, contact the Clinic Manager of the clinic where you were treated. 

Request to restrict certain uses and disclosures of your information. You have the 
right to ask that we restrict how your health information is used or disclosed. 
Under the law, we are not required to agree to your request. In some cases, we 
may not be able to agree to your request because we do not have a way to tell 
everyone who would need to know about the restriction. There are other 
instances in which we are not required to agree with your request. We will 
inform you when we cannot find a way to carry out your request. You may 
request a restriction in these ways: 
• Ask during the registration or sign-in process; 
• Ask the person giving you care (e.g., physician, nursing staff) 
• Contact the Clinic Manager; or 
• Contact the Central Business Office for billing-related requests. 

Receive information at a different place or by different means. You have the right 
to ask that we send information to you in different ways or at different places. 
For example, you may wish to receive a test result at an address other than your 
home address. We will grant reasonable requests. 

Receive a record of how we disclosed your health information. You have the 
right to ask us in writing for a list of places or persons with whom your health 
information was disclosed during the past six years. The list will contain the date 
your health information was disclosed to others, who received the information, a 
brief description of what was disclosed and why. However, the list will not 
include disclosures for the following purposes: treatment, payment, health care 
operations, family and friends for care and payment, national security or 
intelligence, and law enforcement/corrections. In addition, the list will not 
include information that was disclosed to you and to others with your 
permission, incidental disclosures and disclosures of limited or de-identified 
health information. We must provide you the list within 60 days of your request, 
unless you agree to a 30-day extension. You will not be charged for this list, 
unless you request more than one list per year. 
• The request must be for health information disclosed on or after April 14, 2003. 
• To request this list, contact the Medical Records Department at the clinic where you were treated. 

Obtain a paper copy of this notice. Upon your request, you may at any time 
receive a paper copy of this notice. This notice is available at the registration 
desks within each clinic, customer service counter at our Central Business Office, 
and our website at www.lakeshoremedicalclinics.com 

File a complaint. You have the right to file a complaint with us if you believe 
your privacy rights have been violated. To file a complaint, call the Clinic 
Manager at the clinic where you were treated. You also have the right to 
complain to the United States Secretary of the Department of Health and Human 
Services. We will not take any action against you for filing a complaint. 

CONTACT FOR INFORMATION, QUESTIONS, OR CONCERNS 

If you have questions or concerns about your privacy rights, LMC’s privacy-
related policies or the information contained in this notice, please contact the 
Clinic Manager at the clinic where you were treated. 

WHO WILL USE THIS NOTICE TO MEET FEDERAL LAW NOTICE REQUIREMENTS 

LMC, through owned and controlled corporate and limited liability affiliates and 
employees of such entities, provides health care to patients, residents and clients 
jointly with health care providers and other organizations. The following 
persons and entities, who have agreed to be bound by this notice, will jointly 
use this notice for convenience to meet federal law requirements; provided that, 
each person and entity is solely and separately responsible and liable for 
complying with this notice and applicable law (and LMC and its affiliates are 
only liable for their own violations): 
• All employed staff or volunteers of LMC, including staff of other affiliated entities. 
• Any health care professional who agrees to be bound by this notice and who 
treats you at any of our clinics with respect to your information stored at the 
clinic. Please be aware that we may have health care professionals that are 
independent contractors, which means they are not employed or controlled 
by LMC. Such independent health care professionals may have different 
policies or notices regarding the use or disclosure of your health information 
stored at their office and that each person or entity is independently 
responsible for their own compliance with this notice and federal and state 
law. You should determine if your health care professional is employed or 
controlled by LMC or one of its controlled entities. 
• Any of our business partners or associates with whom we share health 
information and who agree to be bound by this notice. 

This notice is effective on and after April 14, 2003, unless and until it is revised by LMC. Revised: May 3, 2007