Mequon Vascular Associates SC / Milwaukee Laser & Body Aesthetics, Ltd.
Notice of Privacy Practices
Effective Date: 10/17/2019
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.
Mequon Vascular Associates SC / Milwaukee Laser & Body Aesthetics, Ltd. is dedicated to keeping your protected health information private. Protected health information includes medical and billing records we have regarding you. This information helps us to provide quality services to you. You have certain rights regarding your protected health information. This notice describes your rights and how Mequon Vascular Associates SC / Milwaukee Laser & Body Aesthetics, Ltd. uses, shares, and protects your protected health information.
Please contact our Privacy Officer with any questions about our notice of privacy practices. Our Privacy Officer can be reached by telephone at 262-240-9640 or in writing at W189 N11100 Kleinmann Dr., Suite 105, Germantown, WI 53022.
Who follows our notice of privacy practices
This notice applies to the following Mequon Vascular Associates SC and Milwaukee Laser & Body Aesthetics, Ltd.’s offices:
Milwaukee Laser & Body Aesthetics, Ltd. W189 N11100 Kleinmann Dr., Suite 105 Germantown, WI 53022 Mequon Vascular Associates SC 11725 N. Port Washington Rd. Suite 250 Mequon, WI 53092 Mequon Vascular Associates SC W189 N11100 Kleinmann Dr., Suite 105 Germantown, WI 53022 Mequon Vascular Associates SC 17000C W Bluemound Rd Suite 110 Brookfield, WI 53005
You have certain rights regarding your protected health information. We may ask you to make some of these requests in writing. You have the right to:
See your protected health information
You can ask to:
- View your protected health information
- Get a copy of your protected health information on paper or in electronic form. We may charge a reasonable, cost-based fee.
Please make these requests in writing and provide them to our Privacy Officer. If we say “no” to your request we will explain why.
Request us to change protected health information
You can ask us to change protected health information about you that you think is not correct or incomplete. Please make these requests in writing and provide them to our Privacy Officer. If we say
“no” to your request we will explain why and ask you to contact us if you do not agree with us.
Request confidential communications
You can ask us to contact you in a specific way. For example, you can request we call you at your home or office telephone at certain times or to send mail to a different address. We may request that you make these requests in writing and provide them to our Privacy Officer. We will say “yes” to requests we can reasonably follow.
Ask us to limit the information we share with others about you
You can ask us not to use or share certain protected health information about you for treatment, payment, or our health care operations. If we say “no” to your request, we will explain the reason to you.
You can also request how we share your information with individuals involved in your care and payment of bills.
If you pay out-of-pocket in full or set up a payment plan before receiving a service or health care item from us, you can ask us not to share that protected health information with your health insurer / health plan for the purpose of payment or operations. We will say “yes” to this type of request unless a law requires us to share that information.
Get a list of those with whom we have shared your protected health information
You can ask us for a list (accounting) of when we disclosed your protected health information under certain situations for the last six years before the day of your request. We will include disclosures we have made unless it was for treatment, payment, and health care operations and certain other disclosures (such as any you asked us to make). We will provide you with one accounting a year for free. We will charge a reasonable, cost-based fee if you ask for another one within 12 months. Please make these requests in writing and provide them to our Privacy Officer.
Get a copy of this notice of privacy practices at any time
You can ask for a paper copy of this notice at any time. If you would like, we will provide you with a paper copy, even if you agreed to receive the notice from us electronically. Please make this request with our Privacy Officer. Our most current notice is also always available on our websites:
- Mequon Vascular Associates SC website address: https://www.mequonvein.com/newpatients/patient–forms/
- Milwaukee Laser & Body Aesthetics, Ltd. website address:
File a complaint if you believe your privacy rights have not been followed
You can complain if you feel your privacy rights have not been followed (have been violated). Please contact our Privacy Officer at 262-240-9640 or in writing at W189 N11100 Kleinmann Dr., Suite 105, Germantown, WI 53022. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a privacy rights complaint about us. We will not require you to waive the right to file a complaint as a condition of receiving treatment.
Choose someone to act for you
If someone is your legal guardian or legal representative, such as an activated power of attorney for health care, that person can exercise your rights and make choices about your protected health information. We will make sure the person has this authority and can act for you.
Our Uses and Disclosures
For certain protected health information, you can tell us your choices about what we share
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions to the best of our abilities. In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, and others involved in your care or payment for services
- Share information in a disaster relief situation to disaster relief agencies
If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
How we typically use and disclose your protected health information
We can use and share your protected health information for the following reasons:
- We can use your protected health information to treat you and share it with other professionals who are treating you. We may share your protected health information with physicians, nurses, lab and radiology technicians, and others involved in your care. Example: A doctor treating you for an injury asks another doctor about your overall health condition
- We can use and share your protected health information to run our organization, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services
- We can use and share your protected health information to bill and get payment from health plans or other parties responsible for payment. Example: We give information about you to your health insurance plan so they will pay for your services
- We may contact you by telephone, cell phone, patient portal (i.e. AdvancedPatient), email, or by mail to communicate with you about appointment reminders, test results, and treatment information
We will not share your protected health information unless you give us written permission for these reasons, unless allowed by law:
- Marketing purposes, except, for example, face-to-face conversations, to provide me with information about treatment alternatives, payment to us is of nominal value
We never sell personal information, unless allowed by law to do so without your authorization.
We will not contact you for fundraising purposes.
More reasons we can use and share your protected health information
We are allowed or required to share your protected health information in other ways. Usually these are ways that contribute to the public good, such as public health and medical research. We have to meet many conditions in the law before we can share your information for these purposes.
Here are a few more examples of when we may be able to use and share your protected health information without your knowledge or authorization:
- For preventing or reducing a serious threat to anyone’s health or safety
- Helping with product recalls
- Reporting adverse reactions to medications
- With health oversight agencies for activities authorized by law, such as audits, inspections, and obtaining licenses
- Reporting disease or infection exposure
- With a coroner, medical examiner, or funeral director when an individual dies for purposes authorized by law, such as for determining the cause of death
- Reporting victims of abuse, neglect, or domestic violence
- For judicial and administrative proceedings such as in response to a court or administrative order
- For law enforcement purposes or with a law enforcement official, such as to identify or locate a suspect, fugitive, or missing person
- With correctional institutions for custodial purposes of inmates
- Reporting crime on our premises
- When required by law
- To comply with workers’ compensation laws for work-related injuries or illness
- For special government functions such as military, veterans, national security, and presidential protective services
- For correctional institutions and law enforcement custody situations
- For provision of public benefits
- To comply with State and Federal laws, such as to the Secretary of the U.S. Department of Health and Human Services Office for Civil Rights if they want to see that we are complying with Federal privacy laws
We are required to maintain the privacy of your protected health information. We are also required to provide you with a copy of this notice which explains our legal duties and privacy practices with respect to your protected health information. We must follow the privacy practices included in this notice.
We will not use or share your protected health information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you do change your mind.
We will let you know if a breach of unsecured protected health information occurs that may have compromised your information.
Changes to the Terms of this Notice
We can change the terms of this notice at any time. Changes that we make will apply to all protected health information we have about you. The new notice will be available in our office, on our web sites, and upon request.
Mequon Vascular Associates SC website address:
Milwaukee Laser & Body Aesthetics, Ltd. website address:
Effective date of this notice of privacy practices: 10/17/2019 Resource: HHS model notice of privacy practices 9/2013