Bellevue Total Health Notice of Privacy Practices
2763 Manitowoc Road, Green Bay, WI 54311
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.
Bellevue Total Health is required, by law, to maintain the privacy and confidentiality
of your protected health information and to provide our patients with notice
of our legal duties and privacy practices with respect to your protected health
Disclosure of Your Health Care Information
We may disclose your health care information to other healthcare professionals
within our practice for the purpose of treatment, payment or healthcare operations.
“On occasion, it may be necessary to seek consultation regarding
your condition from other health care providers associated with Bellevue Total Health.”
“It is our policy to provide a substitute health care provider,
authorized by Bellevue Total Health to provide assessment and/or treatment to our patients,
without advanced notice, in the event of your primary health care provider’s
absence due to vacation, sickness, or other emergency situation.”
We may disclose your health information to your insurance provider for the purpose
of payment or health care operations.
We may disclose your health information as necessary to comply with State Workers’
We may disclose your health information to notify or assist in notifying a family
member, or another person responsible for your care about your medical condition
or in the event of an emergency or of your death.
As required by law, we may disclose your health information to public health
authorities for purposes related to: preventing or controlling disease, injury
or disability, reporting child abuse or neglect, reporting domestic violence,
reporting to the Food and Drug Administration problems with products and reactions
to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings.
We may disclose your health information in the course of any administrative
or judicial proceeding.
We may disclose your health information to a law enforcement official for purposes
such as identifying or locating a suspect, fugitive, material witness or missing
person, complying with a court order or subpoena, and other law enforcement
We may disclose your health information to coroners or medical examiners.
We may disclose your health information to organizations involved in procuring,
banking, or transplanting organs and tissues.
We may disclose your health information to researchers conducting research that
has been approved by an Institutional Review Board.
It may be necessary to disclose your health information to appropriate persons
in order to prevent or lessen a serious and imminent threat to the health or
safety of a particular person or to the general public.
Specialized Government Agencies.
We may disclose your health information for military, national security, prisoner
and government benefits purposes.
Change of Ownership.
In the event that Bellevue Total Health is sold or merged with another organization, your
health information/record will become the property of the new owner.
Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures
of your health information. Please be advised, however, that Bellevue Total Health is
not required to agree to the restriction that you requested.
- You have the right to have your health information received or communicated
through an alternative method or sent to an alternative location other than
the usual method of communication or delivery, upon your request.
- You have the right to inspect and copy your health information.
- You have a right to request that Bellevue Total Health amend your protected health
information. Please be advised, however, that Bellevue Total Health is not required to
agree to amend your protected health information. If your request to amend
your health information has been denied, you will be provided with an explanation
of our denial reason(s)and information about how you can disagree with the
- You have a right to receive an accounting of disclosures of your protected
health information made by Bellevue Total Health.
- You have a right to a paper copy of this Notice of Privacy Practices at
any time upon request.
Changes to this Notice of Privacy Practices
Bellevue Total Health reserves the right to amend this Notice of Privacy Practices at any
time in the future, and will make the new provisions effective for all information
that it maintains. Until such amendment is made, Bellevue Total Health is required by law
to comply with this Notice.
Bellevue Total Health is required by law to maintain the privacy of your health information
and to provide you with notice of its legal duties and privacy practices with
respect to your health information. If you have questions about any part of
this notice or if you want more information about your privacy rights, please
contact: Dr. Bradley Kenny by calling this office at 920.468.8288. If Dr. Bradley Kenny is not available,
you may make an appointment for a personal conference in person or by telephone
within 2 working days.
Complaints about your Privacy rights, or how Bellevue Total Health has handled your health
information should be directed to Dr. Bradley Kenny, by calling this office at 920.468.8288
If Dr. Bradley Kenny is not available, you may make an appointment for a personal conference
in person or by telephone within 2 working days.
If you are not satisfied with the manner in which this office handles your
complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201