Privacy Policy

Notice of privacy practices.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USEDAND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Sansara Concierge Medicine, S.C. (“Sansara”) is required by law to maintain the privacy of your health information. Sansara is also required to provide you with a notice that describes Sansara’s legal duties and privacy practices and your privacy rights with respect to your health information. Sansara will follow the privacy practices described in this notice. If you have any questions about any part of this Notice or if you want more information about the privacy practices of Sansara, please contact Dr. Ruchira Varshney at (414) 850-7356.

Sansara reserves the right to change the privacy practices described in this notice for any reason, including if its practices need to be changed to follow the law. Sansara will make the new notice provisions effective for all the protected health information that Sansara maintains. If Sansara changes its privacy practices, Sansara will have them available upon request. This notice will also be posted at the location of service.

How Sansara May Use or Disclose Your Health Information for Treatment, Payment or Health Care Operations

The following categories describe the ways that Sansara may use and disclose your health information. For each type of use and disclosure, Sansara will explain what is meant and present some examples.

Treatment

Sansara may use or disclose your health care information in the provision, coordination or management of your health care. Communications to you may be by telehealth, telephone, cell phone, email, patient portal, mail or text. For example, Sansara may use your information to call and remind you of an appointment or to refer your care to another physician. If another provider requests your health information and they are not providing care and treatment to you, Sansara will request an authorization from you before providing your information.

Payment

Sansara may use or disclose your health care information to obtain payment for your health care services.

Health Care Operations

Sansara may use or disclose your health care information for activities relating to the evaluation of patient care, evaluating the performance of health care providers, business planning and compliance with the law. For example, Sansara may use your information to determine the quality of care you received or to evaluate services included in its concierge program. If these activities require disclosure outside of its health care organization, Sansara will request your authorization before disclosing that information.

How Sansara May Use or Disclose Your Health Information Without Your Written Authorization

The following categories describe the ways that Sansara may use and disclose your health information without your authorization. For each type of use and disclosure, Sansara will explain what is meant and present some examples.

Required by Law. Sansara may use and disclose your health information when that use or disclosure is required by law. For example, Sansara may disclose medical information to report child abuse or to respond to a court order.
Public Health. Sansara may release your health information to local, state or federal public health agencies subject to the provisions of applicable state and federal law for reporting communicable diseases, aiding in the prevention or control of certain diseases and reporting problems with products and reactions to medications to the Food and Drug Administration.
Victims of Abuse, Neglect or Violence. Sansara may disclose your information to a government authority authorized by law to receive reports of abuse, neglect or violence relating to children or the elderly.
Health Oversight Activities. Sansara may disclose your health information to health agencies authorized by law to conduct audits, investigations, inspections, licensure and other proceedings related to oversight of the health care system.
Judicial and Administrative Proceedings. Sansara may disclose your health information in the course of an administrative or judicial proceeding or otherwise in response to a court order. Under most circumstances, the request for disclosure is made through a subpoena, a discovery request or involves another type of administrative order which must meet conditions for disclosure.
Law Enforcement. Sansara may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purposes. Under some limited circumstances Sansara will request your authorization prior to permitting disclosure.
Coroners and Medical Examiners. Sansara may disclose your health information to coroners and medical examiners. For example, this may be necessary to determine the cause of death.
Research. Under certain circumstances, and only after a special approval process, Sansara may use and disclose your health information to help conduct medical research which may involve an assessment of how well a drug is working to cure a heart disease or whether a certain treatment is working better than another.
To Avert a Serious Threat to Health of Safety. Sansara may disclose your health information in a very limited manner to appropriate persons to prevent a serious threat to the health or safety of a particular person or the general public. Disclosure is usually limited to law enforcement personnel who are involved in protecting the public safety.
Specialized Government Functions. Under certain and very limited circumstances, Sansara may disclose your health care information for military, national security, or law enforcement custodial situations.
Workers’ Compensation. Both state and federal law allow the disclosure of your health care information that is reasonably related to a worker’s compensation injury to be disclosed without your authorization. While Sansara does not accept any payments from these programs, these programs may provide benefits to you for work-related injuries or illness.
Health Information. Sansara may use or disclose your health information to provide information to you about treatment alternatives or other health related benefits and services that may be of interest to you.

When Sansara Will Obtain an Authorization to Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, Sansara generally will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of psychotherapy, marketing and the sale of protected health information require your authorization. If Sansara intends to engage in fundraising, you may have the right to opt out of receiving such communications. If you authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, Sansara will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though Sansara will be unable to take back any disclosures Sansara have already made under your authorization.

Your Health Information Rights

Inspect and Copy Your Health Information. You may inspect and obtain a copy of your health care information. You have the right to request that the copy be provided in an electronic form or format (e.g., PDF saved onto an electronic device). If the form and format are not readily producible, then Sansara will work with you to provide it in a reasonable electronic form or format. For example, you may request a copy of your immunization record from your health care provider. This access does not apply to psychotherapy notes, which are maintained for the personal use of the mental health professional. Your request for inspection or access must be submitted in writing to Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092. In addition, Sansara may charge you a reasonable fee to cover its expenses for copying your health information.
Request to Correct Your Health Information. You may request that Sansara amend your health information that you believe is incorrect or incomplete. For example, if you believe the date of you heart surgery is incorrect, you may request that the information be corrected. Sansara is not required to change your health information and if your request is denied, Sansara will provide you with information about its denial and how you can disagree with the denial. To request an amendment, you must make your request in writing to Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092. You must also provide a reason for your request.
Request Restrictions on Certain Uses and Disclosures. You may request restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment, payments to Sansara or its health care operation activities. For example, if you are an employee of Sansara and you receive health care services from Dr. Ruchira Varshney, you may request that your medical record not be stored with other employees of Sansara. If you would like to make a request for restrictions, you must submit your request in writing to Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092. A restriction cannot be applied to your health information that has already been disclosed.
Receive Confidential Communications of Health Information. You may request that Sansara communicate your health information to you in different ways or places. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address. Sansara must accommodate reasonable requests. To request confidential communications, you must submit your request in writing Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092.
Receive A Record of Disclosures of Your Health Information. You may request a list of the disclosures of your health information that Sansara has made in compliance with federal and state law. This list might include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. For some types of disclosures, the list could also include the date and time the request for disclosure was received and the date and time the disclosure was made. For example, you may request a list that indicates all the disclosures your health care provider has made from your health care record in the past six months. To request a list of disclosures, you must submit your request in writing to Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092. Sansara will comply with your request for a list within 60 days, unless you agree to a 30-day extension, and Sansara will not charge you for the list, unless you request such list more than once per year.
Obtain A Paper Copy of This Notice. Upon your request, you may at any time receive a paper copy of this notice, even if you earlier agreed to receive this notice electronically. To obtain a paper copy of this Notice, send your written request to Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092.
Notice of a Breach. Certain federal or state laws may require Sansara to notify you following a breach of certain unsecured protected health information.
Complaint. If you believe your privacy rights have been violated, you may file a complaint with Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092 who will provide you with any needed assistance. Sansara requests that you file your complaint in writing so that Sansara may better assist in the investigation of your complaint. In addition, you may have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services (DHHS). If your complaint relates to your privacy rights while you were receiving treatment for mental illness, alcohol or drug abuse or a developmental disability you may also file a complaint with the staff or administrator of the treatment facility or community mental health program. There will be no retaliation against you in any way for filing a complaint.

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact Dr. Ruchira Varshney, 10335 North Port Washington Road, Suite 180, Mequon, WI 53092.

Effective Date of this Notice: July 21, 2023