Privacy Notice

As required by The Federal Health Insurance Portability and Accountability Act of 1996

 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.  If you have any questions about this Notice, please contact our Privacy Officer at 231-882-9661, ext. 20.

 Your medical information is personal.  We are committed to protecting your medical information.  We create a record of the care and services you receive at this office.  We need this record to provide you with quality care and to comply with certain legal requirements.  This Notice applies to all of the records of your care generated by this office whether made by your personal physician/provider or one of our staff employees.  This Notice will tell you about the ways in which we may use and disclose your medical information.  This Notice will also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.  We are required by law to (1) make sure that medical information that identifies you is kept private, (2) give you this Notice of our legal duties and privacy practices with respect to medical information about you and (3) follow the terms of the Notice that is currently in effect.

REVISIONS TO THIS NOTICE:  We reserve the right to revise this Notice.  Any revised Notice will be effective for medical information we already have about you as well as any information we receive in the future.  We will post a copy of any revised Notice in this office.  Any revised Notice will contain the new effective date.  Upon your request, we will provide you with the revised Notice of Privacy Practices by call the offices and requesting a revised copy be sent by mail or by asking for one at your next visit.

 USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION:  You will be asked by our staff to sign a document acknowledging your receipt of our Notice of Privacy Practices.  Following are examples of the types of uses and disclosures of your protected health care information that we are permitted to make.  These examples are not meant to be exhaustive, but will fit within on of these general categories:

 TREATMENT:  We will use and disclosure your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information.  For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  We will also disclose protected health information to other physicians/providers who may be treating you when we have the necessary permission from you to disclose your protected health information.  For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.  In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g. a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

 PAYMENT:  Your protected health information will be used, as needed, to obtain payment for your health care services.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

 HEALTHCARE OPERATIONS:  We may use and disclose medical information about you for office operations.  These uses and disclosures are necessary to run our offices and make sure that all of our patients receive quality care.  These activities include, but are not limited to quality assessment activities, employee review activities, training of medical students, licensing, and marketing activities, and conducting or arranging for other business activities.  For example, we may disclose your protected health information to medical school students that see patients at our offices.  In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician/provider.  We may also call you by name in the waiting room when your physician is ready to see you.  We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.  We will share your protected health information with third party “business associates” that perform various activities   (e.g. billing, record copying service, transcription services) for the practice.  Whenever an arrangement between our offices and a business associate involves the use of disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.  We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.  We may also use and disclose your protected health information for other marketing activities.  For example, your name and address may be used to send you a newsletter about our practice and the services we offer.  We may also send you information about products or services that we believe may be beneficial to you.  You may contact our Privacy Officer to request that these materials not be sent to you.

 USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN AUTHORIZATION:  Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.  You may revoke this authorization, at any time, in writing, except to the extent that your physician/provider or the practice has already taken an action regarding the use of disclosure indicated in the authorization.

 OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT:  We may use and disclose your protected health information in the following instances.  You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.  If you are not present or able to agree or object to the use or disclosure of the protected information, then your physician/provider may, using professional judgment, determine whether the disclosure is in your best interest.  In this care, only the protected health information that is relevant to your health care will be disclosed.

 OTHERS INVOLVED IN YOUR HEALTHCARE:  Unless you object, we may disclose to a member of your family, a relative, a close friend, a doctor, staff or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

 EMERGENCIES:  We may use or disclose your protected health information in an emergency treatment situation.  If this happens, your physician/provider shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment.  If your physician/provider or another physician/provider in the practice is required by law to treat you and the physician/provider has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.

 COMMUNICATION BARRIERS:  We may use and disclose your protected health information if your physician/provider or another physician/provider in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician/provider determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

 OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT:  We may use or disclose your protected health information in the following situations without your consent or authorization.  These situations include:

           AS REQUIRED BY LAW:  We will disclose medical information about you when required to do so by federal, state or local laws.  For example, disclosure may be required by Workers’ Compensation statutes and various public health statutes in connection with required reporting of certain diseases, child abuse, domestic violence, adverse drug reaction, etc.

             PUBLIC HEALTH:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

            COMMUNICABLE DISEASES:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

             HEALTH OVERSIGHT:  We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

            CERTIFYING AGENCIES:  We may disclose protected health information to certifying agencies either private or governmental for activities such as audits and inspections.

             ABUSE OR NEGLECT:  We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

             FOOD AND DRUG ADMINISTRATION:  We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

             LEGAL PROCEEDINGS:  We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

             LAW ENFORCEMENT:  We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes.  These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises, and (6) medical emergency (not on the premises) and it is likely that a crime has occurred. 

            CORONERS, FUNERAL DIRECTORS, AND ORGAN DONATION:  We may release medical information to a coroner or medical examiner to identify a deceased person or determine the cause of death.  We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Protected health information may be used and disclosed for cadaver organ, eye or tissue donation purposes.

             RESEARCH:  We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.,

             CRIMINAL ACTIVITY:   Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

             MILITARY ACTIVITY AND NATIONAL SECURITY:  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs or your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or other legally authorized.

             WORKERS’ COMPENSATION:  Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.

             INMATES:  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician/provider created or received your protected health information in the course of providing care to you.

             REQUIRED USES AND DISCLOSURES:  Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. Seq.

             OTHER USES OF MEDICAL INFORMATION:  Other uses and disclosures of your medical information not covered by this Notice of Privacy Practices will be made only with your written authorization.  If you provide us such an authorization in writing to use or disclose medical information about you, you may revoke that authorization, in writing, at any time.  If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.

 YOUR RIGHTS 

The following is a statement of your rights with request to your protected health information and a brief description of how you may exercise these rights.

 You have the right to inspect and receive a copy of your protected health information.  This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information.  A “designated record set” contains medical and billing records (Non-Active Patients:  medical records retained for 10 years, billing records retained for 7 years) and any other record that your physician/provider and the office uses for making decisions about you.

 Under federal law, however, you may not inspect or copy the following records:  psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.  Depending on the circumstances, a decision to deny access may be reviewable.  In some circumstances, you may have a right to have this decision reviewed.  Please contact our Privacy Officer if you have questions about access to your medical record.  There will be a charge of $.20 per page associated with the copying of your patient chart. 

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply.  Your request will be given to the Privacy Officer who will contact you (within ten (10) business days) to review your request and explain how your request will be handled.  Your physician/provider is not required to agree to a restriction that you may request.  If the physician/provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.  If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.

 You have the right to request to receive confidential communications from us by alternative means or at an alternative location.  We will accommodate reasonable requests.  We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request.  Please make this request in writing,  Your request will be given to the Privacy Officer who will contact you (within ten (10) business days) to review your request and explain how your request will be handled.

 You may have the right to have your physician/provider amend your protected health information:  This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and provide you with a copy of any such rebuttal.  Please contact our Privacy Officer to determine if you have questions about amending your medical record.

 You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes.  You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.  The right to receive this information is subject to certain exceptions, restrictions and limitations.

 COMPLAINTS:  You may complain to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights.  You may file a complain with us by notifying our Privacy Officer in writing of your complaint.  We will not retaliate against you for filing a complaint. 

You may contact our Privacy Officer, at 231-882-9661, ext. 1036 for further information about the complaint process.

This notice was published and becomes effective on April 14, 2003.