NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW APPLETON CARDIOLOGY ASSOCIATES, LTD MAY USE AND DISCLOSE YOUR HEALTHCARE INFORMATION AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY

Appleton Cardiology Associates, Ltd. Is required by law to maintain the privacy of your protected health information. This information consists of all records related to your health, including demographic information, either created by Appleton Cardiology Associates, Ltd. Or received by Appleton Cardiology Associates, Ltd. From other healthcare providers.

We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. Appleton Cardiology Associates, Ltd. Will abide by the terms of the Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information.

Appleton Cardiology Associates, Ltd. Reserves the right to change the terms of this Notice and to make any new provisions effective for all protected health information that we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time.

Uses and Disclosures of Your Protected Health Information not Requiring Your Consent

Appleton Cardiology Associates, Ltd. May use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment and healthcare operations. There are certain restrictions on uses and disclosures of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence. There are also restrictions on disclosing HIV test results.

Treatment may include:

Providing, coordinating, or managing healthcare and related services by one or more healthcare providers;

Consultations between healthcare providers concerning a patient;

Referrals to other providers for treatment;

Referrals to nursing homes, foster care homes, or home health agencies.

For example, Appleton Cardiology Associates, Ltd. May determine that you require the services of a specialist, In referring you to another doctor, Appleton Cardiology Associates, Ltd. May share or transfer your healthcare information to that doctor.

Payment activities may include:

Activities undertaken by Appleton Cardiology Associates, Ltd. to obtain reimbursement for services provided to you;

Determining your eligibility for benefits or health insurance coverage;

Managing claims and contacting your insurance company regarding payment;

Collection activities to obtain payment for services provided to you;

Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under you health plan, appropriateness of care, or justification of charges;

Obtaining pre-certification and pre-authorization of services to be provided to you.

For example, Appleton Cardiology Associates, Ltd. will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided to you.

Healthcare operations may include:

Contacting healthcare providers and patients with information about treatment alternatives;

Conducting quality assessment and improvement activities;

Conducting outcomes evaluations and development of clinical guidelines;

Protocol development, case management, or care coordination;

Conducting or arranging for medical review, legal services, and auditing functions.

For example, Appleton Cardiology Associates, Ltd. may use your diagnosis, treatment, and outcome information to measure the quality of the services that we provide. Or assess the effectiveness of your treatment when compared to patients in similar situations.

Appleton Cardiology Associates, Ltd. may contact you, by telephone or mail, to provide appointment reminders. You must notify us if you do not wish to receive appointment reminders.

We may use our professional judgment to disclose your protected health information to family members or friends who may be involved with your treatment or care or to notify, or assist in the notification of, a family member or other individual responsible for your care, of your location, general condition or death. This disclosure is subject to your opportunity to object in the event you are present. Health information may be released without written permission to a parent, guardian, or legal custodian of a child; the guardian of an incompetent adult; the health care agent designated in an incapacitated patient?s health care power of attorney; or the personal representative or spouse of a deceased patient.

There are additional situations when Appleton Cardiology Associates, Ltd. is permitted or required to use or disclose your protected health information without your consent or authorization. Examples include the following:

In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries. We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe that the wound occurred as a result of a crime. Mental Health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on our premises.

For public health activities
We may release healthcare records, with the exception of treatment records, to certain government agencies or public health authority authorized by law, upon receipt of written request from the agency. We are required to report positive HIV test results to the state epidemiologist. We may also disclose HIV test results to other providers or persons when there has been or will be risk of exposure.

We may report to the state epidemiologist the name of any person know to have been significantly exposed to a patient who tests positive for HIV. We are required by law to report suspected child abuse and neglect and suspected abuse of an unborn child, but cannot disclose HIV test results in connection with the reporting or prosecution of alleged abuse or neglect. We may release healthcare records, including treatment records and HIV test results, to the Food and Drug Administration when required by federal law. We may disclose healthcare records, except for HIV test results, for the purpose of reporting elder abuse or neglect, provided the subject of the abuse or neglect agrees, or if necessary to prevent serious harm. Records may be released for the reporting of domestic violence if necessary to protect the patient or community from imminent and substantial danger.

For health oversight activities.
We may disclose healthcare records, including treatment records, in response to a written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification. HIV test results may not be released to federal or state governmental agencies, without written permission, except to the state epidemiologist for surveillance, investigation, or to control communicable diseases.

Judicial and Administrative Proceedings.
Patient healthcare records, including treatment records and HIV test results, may be disclosed pursuant to a lawful court order. A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records except for HIV test results.

For activities related to death.
We may disclose patient healthcare records, except for treatment records, to a coroner or medical examiner for the purpose of completing a medical certificate or investigating a death. HIV test results may be disclosed under certain circumstances.

For research.
Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.

To avoid a serious threat to health or safety.
We may report a patient?s name and other relevant data to the Department of Transportation if it is believed the patient?s vision or physical or mental condition affects the patient?s ability to exercise reasonable or ordinary control over a motor vehicle. Healthcare information, including treatment records and HIV test results, may be disclosed where disclosure is necessary to protect the patient or community from imminent and substantial danger.

For worker?s compensation.
We may disclose your health information to the extent such records are reasonably related to any injury for which workers compensation is claimed.

For victims of abuse, neglect, or domestic violence.
We may notify the appropriate government authority if we believe a patient or resident has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree, or when required or authorized by law.

For law enforcement purposes.
We may disclose your private health information if asked to do so by a law enforcement official in the following circumstances:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person?s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at our facility; and
- In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

For organ/tissue donation.
We may disclose health information to organizations that handle organ procurement or organ, eye or tissue transportation or to an organ donation bank to facilitate organ or tissue donation and transplantation.

For specialized government functions.
In certain circumstances, we may use or disclose your health information to facilitate specified government functions. - Military and Veterans. We may disclose the health information of armed forces personnel as required by military command authorities for the proper execution of a military mission.
- National Security and Intelligence Activities. We may disclose your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
- Protective Services for the President and Others. We may disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
- Medical Suitability Determinations. We may disclose your health information to the Department of State for use in making medical suitability determinations.
- Inmates and Law Enforcement Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement officials, we may release the health information of inmates and others in law enforcement custody to the correctional institution or law enforcement official, where necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Appleton Cardiology Associates, Ltd. will not make any other use or disclosure of your protected health information without your written authorization. You may revoke such authorization at any time, except to the extent that Appleton Cardiology Associates, Ltd.. Has taken action in reliance thereon. Any revocation must be in writing.

Your Rights Regarding Your Protected Health Information

You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by Appleton Cardiology Associates, Ltd. to carry out treatment, payment, or healthcare operations. You must request such a restriction in writing. We are not required to agree to your request, but if we do agree, we must adhere to the restriction, except when your protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to health care providers treating you. Also, a restriction would not apply when we are required by law to disclose certain healthcare information. Appleton Cardiology Associates, Ltd. shall respond to your request for restrictions in a timely manner.

You have the right to review and/or obtain a copy of your healthcare records, with the exception of psychotherapy notes, or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding. Appleton Cardiology Associates, Ltd. may deny an access under other circumstances, in which case you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records. Appleton Cardiology Associates, Ltd. shall provide protected health information for your review and for copying in a timely manner.

You may request that Appleton Cardiology Associates, Ltd. send protected health information, including billing information, to you by alternative means or to alternative locations. You may also request that Appleton Cardiology Associates, Ltd. not send information to a particular address or location or contact you at a specific location, perhaps your place of employment. This request must be submitted in writing. We will accommodate reasonable requests by you.

You have the right to request that Appleton Cardiology Associates, Ltd. amend portions of your healthcare records, as long as such information is maintained by us. You must submit this request in writing, and under certain circumstances the request may be denied. Appleton Cardiology Associates, Ltd. shall respond to your request for amendment in a timely manner.

You may request to receive an accounting of the disclosures of your protected health information made by Appleton Cardiology Associates, Ltd. for six years prior to the date of the request, beginning with disclosures made after April 14, 2003. We are not required, however, to record disclosures we make pursuant to a signed consent or authorization.

You may request a paper copy of this Notice, if you had previously received or agreed to receive the Notice electronically.

Any person or patient may file a complaint with Appleton Cardiology Associates, Ltd. and/or the Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with Appleton Cardiology Associates, Ltd., please contact the Privacy Officer at the following:

Appleton Cardiology Associations, Ltd.
1818 N. Meade Street, 3rd Floor
Appleton , WI 54911
(920) 731-8900

It is the policy of Appleton Cardiology Associates, Ltd. that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance or violation of the privacy standards.

In cases where Wisconsin state law regarding the use and disclosure of protected health information places greater limits on the manner in which your protected health information can be used or disclosed as compared to those requirements found in the Health Insurance Portability and Accountability Act, these more protective state law provisions will govern the use and disclosure of your protected health information by Appleton Cardiology Associates, Ltd.

This Notice of Privacy Practices is effective April 14, 2003.

(APPLETON CARDIOLOGY ASSOCIATES, LTD.) Notice of Privacy Practices Effective April 14, 2003