Privacy Policy

Notice of Privacy Practices and E-Prescribing Information and Patient Consent

MORELAND OB-GYN ASSOCIATES, S.C.(hereafter referred to as MOBGYN). 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.

Download a printable copy of our privacy policy here.

Your Health Care Information – Protecting Your Privacy

It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.

Moreland OB-GYN’s Responsibilities

It is your right as a patient to be informed of MOBGYN’s legal duties with respect to protection of the privacy of your personal health information.

Moreland OB-GYN’s Responsibilities

It is your right as a patient to be informed of MOBGYN’s legal duties with respect to protection of the privacy of your personal health information.

  • Maintain the privacy of your health information
  • Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; and
  • Abide by the terms of this notice.

MOBGYN reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. MOBGYN also reserves the right to change the terms of its notice with respect to any applicable more limited uses and disclosures.

MOBGYN will promptly revise and distribute its notice whenever MOBGYN makes a substantial change to any of its privacy practices.

MOBGYN will not use or disclose your health information without your authorization, except as described in this notice.

Your Health Information Rights You have the right to:

  • Request a restriction on certain uses and disclosures of your health information.
    You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or MOBGYN’s payment or health care operation activi¬ties. However, MOBGYN is not required to agree to your requested restriction.
  • Receive Confidential Communications.
    You have the right to request that MOBGYN communicate your health information to you by alternative means or at alternative locations. MOBGYN shall accommodate reasonable requests.
  • Inspect and obtain a copy of your health record.
    You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be submitted in writing to the Privacy Officer. This right may not apply to certain types of psychotherapy notes and MOBGYN may charge you a reasonable fee for a copy of your health care record.
  • Amend your health record.
    You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health record should be changed. If MOBGYN did not create the health information you believe is incorrect or if MOBGYN disagrees with you, MOBGYN may deny your request.
  • Obtain an accounting of disclosures of your health information.
    You have the right to an accounting of disclosures of your health information that MOBGYN has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. You will receive one accounting per year, if desired, at no charge and MOBGYN may charge you a reasonable fee for each subsequent request.
  • Obtain a paper copy of the notice upon request.
    You have the right to obtain a paper copy of the notice upon request.

Uses and Disclosures for Treatment, Payment and Health Care Operations

MOBGYN is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.

MOBGYN may use or disclose your health information for treatment.

MOBGYN may use or disclose your health information in the provision, coordination or management of your health care.

Your information may be disclosed from one OB-GYN doctor to another if they are consulting each other in relation to your care and treatment.

MOBGYN may use your health information to provide you with an appointment reminder.

MOBGYN may send you information about treatment alternatives or other health related services that may be of interest to you.

MOBGYN may use or disclose your health information for payment.

MOBGYN may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis and your treatment.

MOBGYN may use or disclose your information to your insurer to obtain payment for the provision of health care services.

MOBGYN may use or disclose your health information for routine health care operations.

MOBGYN may use or disclose your health information for evaluation: of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.

Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization

Without your written authorization, MOBGYN may use or disclose your health information for the following purposes:

As Required by Law: MOBGYN may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or requirements of state law include the following:

  • Disclosures about victims of elderly or child abuse
  • Disclosures for judicial and administrative proceedings
  • Disclosures for law enforcement purposes

Public Health: As required by law, MOBGYN may disclose your protected health information to the State of Wisconsin for the purpose of statutory reporting.

MOBGYN may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.

MOBGYN may disclose your protected health information excluding your HIV test result without your authorization to a county agency investigating child abuse.

MOBGYN may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result without your authorization to the Food and Drug Administration (FDA).

MOBGYN may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.

MOBGYN may disclose your protected health information that is reasonably related to a work related illness or injury if an application for workers’ compensation has been filed.

Victims of Abuse, Neglect or Domestic Violence: MOBGYN may disclose health information except for an HIV test result if MOBGYN reasonably believes that an individual is a victim of child or elderly abuse.

Health Oversite Activities: MOBGYN will not disclose HIV test results to health care oversite agencies without an authorization. MOBGYN may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your protected health information may be disclosed without your authorization to a state or federal agency.

Judicial and Administrative Proceedings: MOBGYN may disclose your protected health information in response to a court order. MOBGYN may disclose your protected health information in response to a subpoena, if MOBGYN is a party to a court action, if MOBGYN has received your authorization to disclose and has not complied within two business days, or MOBGYN failed to respond to a request for workers’ compensation records. MOBGYN may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result in response to a subpoena from a state or federal agency.

Law Enforcement: MOBGYN may disclose your protected health information except for HIV test results to county law enforcement officials for the reporting and investigation of elderly and/or child abuse. MOBGYN may disclose your protected health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results to state and federal law enforcement officials. MOBGYN may disclose mental health, alcohol or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. MOBGYN may disclose your protected health information to a law enforcement official in response to a court order.

For Activities Related to Death:

Coroner or Medical Examiner: MOBGYN may use or disclose your protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse and developmental disabilities to a coroner or medical examiner.

Funeral Director: MOBGYN may use or disclose your HIV test result to a funeral director.

For Cadaveric Organ, Eye or Tissue Donation Purposes: MOBGYN may use or disclose your HIV test result to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation or cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.

Research: MOBGYN may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.

To Avoid a Serious Threat to Health or Safety: MOBGYN may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.

Disclosures for Specialized Government Functions: MOBGYN may disclose protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result for national security, for protection of the President and for medical suitability determination or of Armed Forces personnel to a state or federal agency.

MOBGYN may disclose protected health information to limited staff of a correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.

Workers Compensation: MOBGYN may disclose protected health information reasonably related to a workers’ compensation injury.

MOBGYN has attempted to explain with this notice the circumstances where state law may be more protective than the federal privacy rule and provides greater privacy protection.

Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your health information requires MOBGYN to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to MOBGYN’s Privacy Officer.

Patient Complaint Process

If you believe your privacy rights have been violated, you may file a complaint with MOBGYN or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint.

To file a complaint with MOBGYN please contact the MOBGYN’s Privacy Officer who will provide you with the necessary assistance.

Questions or Concerns

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:
Moreland OB-GYN Associates, S.C.
1111 Delafield Street
Suite 311 Waukesha, Wl 53188
(262) 544-4411
FAX (262) 650-3856
Privacy Officer

Contact Us

Phone: 262-544-4411
Fax: 262-650-3856

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Moreland OB/GYN-Lake Country offers three locations in Delafield, Oconomowoc & Watertown.

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