Forward Ketamine of Wisconsin
HIPAA-Compliant Privacy Policy
Effective Date: February 1, 2023
Introduction
Forward Ketamine of Wisconsin (“the Clinic,” “we,” “our”) is committed to maintaining the privacy and
security of your protected health information (PHI). This Privacy Policy describes how we may use and
disclose your PHI, your rights regarding your PHI, and our responsibilities under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
Our Responsibilities
We are required by law to: – Maintain the privacy of your PHI. – Provide you with this Notice of our legal
duties and privacy practices. – Notify you in the event of a breach of unsecured PHI. – Follow the terms of
this Notice as long as it is in effect.
How We May Use and Disclose Your PHI
We may use or disclose your PHI for the following purposes as permitted or required by law:
1. Treatment
We may use or share your PHI to provide, coordinate, or manage your healthcare and related services. This
includes communication with other healthcare providers involved in your care.
2. Payment
We may use or disclose your PHI to obtain payment for services rendered. This may include
communications with insurance companies, billing departments, or financial institutions.
3. Healthcare Operations
We may use or disclose your PHI for healthcare operations such as quality assessment, staff training,
licensing, accreditation, and administrative activities.
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4. Required or Permitted by Law
We may disclose your PHI when required by federal, state, or local laws, including: – Public health activities –
Judicial or administrative proceedings – Law enforcement requests – Organ and tissue donation processes –
Serious threat to health or safety
5. Business Associates
We may share your PHI with third-party business associates who perform services on our behalf, provided
they agree to protect your information.
Uses and Disclosures Requiring Your Authorization
We must obtain your written authorization before using or disclosing your PHI for purposes not described
in this Notice, including: – Most uses of psychotherapy notes – Marketing communications – Sale of PHI
You may revoke an authorization in writing at any time, except to the extent that action has already been
taken.
Your Rights Regarding Your PHI
You have the following rights under HIPAA:
1. Right to Access
You may request to inspect or obtain a copy of your PHI in designated record sets. Requests must be
submitted in writing.
2. Right to Amend
If you believe your PHI is incorrect or incomplete, you may request an amendment in writing. We may deny
requests under certain conditions.
3. Right to an Accounting of Disclosures
You may request a list of disclosures of your PHI made by the Clinic, except those for treatment, payment,
healthcare operations, or those authorized by you.
4. Right to Request Restrictions
You may request restrictions on how we use or disclose your PHI. While we are not required to agree, we
will comply with restrictions related to services paid entirely out-of-pocket.
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5. Right to Request Confidential Communications
You may request that we communicate with you through specific channels (e.g., alternative phone number
or address).
6. Right to Receive a Paper Copy
You may request a paper copy of this Notice at any time.
Contact Information
If you have questions about this Notice, want to exercise your privacy rights, or need to file a complaint,
please contact:
Matthew Vasey
Phone: 608-898-4818
Complaints may also be filed with the U.S. Department of Health and Human Services. We will not retaliate
against you for filing a complaint.
Changes to This Notice
We reserve the right to change this Privacy Policy at any time. Changes will apply to all PHI we maintain and
will be available upon request and posted at our facility.
Thank you for trusting Forward Ketamine of Wisconsin with your care.
