Your information. Your Rights. Our Responsibilities.

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Tellurian complies with both the Health Information Portability and Accountability Act of 1996 and 42 CFR Part 2. deferring to whichever places greater limits on disclosures. Please review carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some our responsibilities to help you.

Get an electronic or paper copy of your treatment record
  • You can ask to see or get a paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee pursuant to Wis. Stat §146.83 (3F) 9(c) 2.
Ask us to correct your treatment record
  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we will tell you why in writing within 60 days.
Request confidential communications
  • You can ask us to contact you in a specific fashion (for example home, office, or mobile phone) or send your mail to a different address.
  • We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
  • You can ask us not to use or share certain mental health or substance abuse information for treatment, payments, or our operations.
  • We may say “no” if it would adversely affect you care.
  • You will be given an opportunity to note acceptable disclosures and/or limitations with every written consent.
Get a list of those with whom we have shared information
  • You can ask for a list (accounting) of the times we have released your treatment records for six years prior to the date you ask, who we shared it with, and for what purpose.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Revoke any consents
  • You may cancel Release of Information authorizations at any time.
  • We do require all revocations be made in writing with an agency representative.
Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has the authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
  • You can complain if you feel we have violated your rights by contacting our HIPAA Compliance and Client Rights Specialist using the information provided on page 4.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington D. C. 20201, calling 1-877-696-6775, or visiting
Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share information in the situations described below, talk to us. Tell us what you want us to do and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
  • Share information with your family, close friends, or others involved in your care.
  • Share information with outside providers.
  • Share information in disaster relief situations.
  • Contact you for fundraising efforts

If you are not able to tell us your preference, for example you are unconscious, we
may go ahead and share 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.

In these cases we never disclose your information unless you give us written permission / consent.
  • Disclosures to outside providers, including your health insurer
  • Marketing
  • Sale of your information
  • Most sharing of psychiatric notes
  • Most sharing of substance abuse counseling notes
Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your information in the following ways.

Treat you
  • We can use and share your health information with staff within our agency.
  • We can use and share your health information with external sources, but only with your written consent.
Run our organization
  • We can use and share your health information to run our programs, improve your care, and contact you when necessary.
Bill for your services
  • We use your health information to bill and get payment from your health insurance plan or other entities, but only with your written consent.

How else can we use or share your health information? We are allowed or required to share information in other ways-usually in ways that contribute to public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

Medical Emergencies
  • Identifying information may be disclosed to medical personnel who have a need for information about you for the purpose of treating a condition which poses an immediate threat to your health and which requires immediate medical intervention.
Help with public health and safety issues

We can share information about you in certain situations such as:

  • Preventing or reducing a serious threat of harm to self or others
  • Reporting suspected abuse, neglect, or domestic violence
  • Reporting adverse reactions to medication
Do research
  • We can use or share your information about you for health research.
  • No identifying information is attached to these disclosures.
Comply with the law
  • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
Respond to lawsuits and legal actions
  • We can share health information about you in response to a court or administrative order, or in response to a subpoena with the exception of substance abuse treatment records.
  • We Substance abuse treatment records only may be disclosed under a unique court order meeting requirements of 42 CFR Part 2. A subpoena alone is not sufficient. Both a court order, signed by a judge, and a subpoena must be issued to compel disclosure.can use and share your health information with external sources, but only with your written consent.
Work with medical examiner or funeral director
  • We can share identifying information relating to a cause of death under laws requiring collection of death or other vital statistics, or permitting inquiry into the case of death.
  • Disclosures can be made to the coroner, medical examiner, or funeral
  • Any other disclosure of the individual as an alcohol or drug abuser requires consent from an executor, administrator, or other personal representative appointed under applicable State law.
Our Responsibilities
  • We are required to establish a Business Associate Agreement (BAA) with any entity who may perform functions or activities on behalf of, or provides certain services to us that involves access by the business associate to your protected health information.
  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than described here unless you tell us we can do so. Consent must be made in writing using a Release of Information form. If you tell us we can, you may change your mind at any time. Revocations are to be made in writing with an agency representative.
Contact Us

Erica Mueller
Client Rights and HIPAA Compliance Officer
5900 Monona Drive, Suite 300
Madison, WI 53716
(608) 204-8547 • Fax (608) 222-6694