[Your Healthcare Company] Provider Notice of Information Practices
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Uses and disclosures of health information 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. [Your Healthcare Company] is required to maintain the privacy of your Protected Health Information (“PHI”) and to provide you with a notice of our legal duties and privacy practices with respect to PHI. PHI is information about you, including basic demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI about you to carry out treatment, to obtain payment for treatment or health care operation (“TPO”) and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you. We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below. Examples of how we may use and disclose PHI: The following categories describe and provide examples of different ways that we may use and disclose PHI about you. Remember these are only examples and will not spell out every situation. We will use PHI for treatment. Example: Information obtained by the [Your Healthcare Company] will be used for your treatment. We will use PHI for payment. Example: We will contact your insurance company or benefit manager to determine whether they will pay for your services and the amount of your co-payments and deductibles. We will have a billing company bill you or we will bill a third party payor for the cost of services provided to you. The information on or accompanying the bill may include information that identifies you as well as the services you received and your diagnosis. We will use PHI for health care operations. Example: The [Your Healthcare Company] may use information in your health record to monitor the quality and effectiveness of the health care and services we provide to you. We are likely to use or disclose PHI for the following purposes: Business Associates: These are some services provide by us through contracts with business associates. Examples of our Business Associates are: Our software vendor that writes and maintains our business software, our collection agencies, our telephone software vendor that writes and maintains our telephone communications, our answering service that takes patient calls after hours, the Physician Health Organizations that provide utilization and contract management for our insurance contracts. Communication with individuals involved in your care or payment for your care: Health professionals such as physicians, using their professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person’s involvement in your care or payment related to your care. In the course of providing care we may: (1) send you an appointment reminder post card, (2) leave a brief message on an answering machine or with someone at the number you have given us indicating our office name, a contact person name and a phone number; (3) your chart may be reviewed in the clinic area by a physician or [Your Healthcare Company] staff, but every effort will be made to keep this information confidential; (4) physicians may dictate in the clinic area, in discreet voices, information regarding you or your health conditions; (5) we will call you into the clinic area by last name or first and last name as appropriate; (6) all [Your Healthcare Company] employees will use discretion when discussing with you either in person or on the telephone any PHI. Food and Drug Administration (FDA): We may disclose to the FDA or its agents PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement. Workers’ Compensation: We may disclose PHI about you to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law. Other Health Care Providers: We may disclose PHI about you for treatment or payment activities of another health care provider. We may also disclose PHI about you to another health care provider for the health care operation’s activities (quality assessments, competence, and performance reviews as well as others) of that health care provider providing they too have a relationship with you. We may also disclose PHI about you to such a health care provider for the purpose of health care fraud and abuse detection or compliance. Public Health: As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Law Enforcement: We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena. As required by law: We must disclose PHI about you when required to do so by law. Health oversight activities: We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws. Judicial and administrative proceedings: If you are involved in a lawsuit or dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI. We are permitted to use or disclose PHI about you for the following purposes: Research: We may disclose PHI about you 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 information. Coroners, medical examiners, and funeral directors: We may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to carry out their duties. Organ or tissue procurement organizations: Consistent with applicable law, we may disclose PHI about you to organ procurement organizations or other entities engaged in procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. Notification: We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Correctional Institutions: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents, PHI necessary for your health and the health and safety of others. To avert a serious threat to health or safety: We may use and disclose PHI about you when necessary to prevent a serious threat to your health or the safety of the public or another person. Military and Veterans: If you are a member of the armed forces, we may releases PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority. National Security and Intelligence Activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective Services for the President and Others: We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. Victims of Abuse, Neglect, or Domestic Violence: We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe that you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you. Other Uses and Disclosures of PHI: The [Your Healthcare Company] will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above or as otherwise permitted or required by law. You may revoke your authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization. Individual Rights [Your Healthcare Company] has designated a Public Relations Director to answer your questions regarding our privacy practices as well as to respond to information requests or complaints. You may contact our Public Relations Director at the address or phone number listed below. You have the following rights with respect to PHI about you: Obtain a paper copy of our Privacy Notice upon request. You may request a paper copy of this notice at anytime, even if you have previously received a copy. To obtain a paper copy, you may request one in person at any of our Offices or by contacting the Public Relations Director. Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use and disclosure of PHI about you by completing a Request for Additional Restrictions form. Forms are available from any of our Offices or by contacting our Public Relations Director. We are not required to agree with your requested restrictions and will notify you within 60 days of our decision to accept or deny your request. Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as the [Your Healthcare Company] maintains the PHI. The “designated record set” usually will include your medical chart and billing records. To inspect or copy PHI about you, you must complete a written request and submit it to our Public Relations Director. The Request for Access to Designated Records Set form can be obtained at any of our Offices or by contacting our Public Relations Director. We may charge you a fee for the costs of copying, mailing, staff time and other supplies that are necessary to grant your request. You will be notified in advance if there will be a charge. We may deny your request to inspect and copy your record in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed. Request an amendment of PHI. If you feel that the PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must submit a written request to the Public Relations Director at the address listed below. The forms for this are available at any of our Office locations or by calling the Public Relations Director. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give you a rebuttal to your statement. Receive an accounting of disclosure of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 or for the past six years whichever is less, for most purposes other than TPO. The accounting will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, and disclosures for notification purposes (recalls). The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit your request in writing to our Public Relations Director. You may obtain the Request for Accounting Disclosure forms form any of our offices or by contacting our Public Relations Director. You must specify the period of time you are requesting the disclosure for, but no farther back that April 14, 2003 or six years whichever is less. The first accounting you request within a 12 month period will be provided free of charge. Any additional accountings will be charged $20 per hour for staff time in addition to $.15 per page. We will notify you of the cost in advance so you can modify or withdraw your request at that time. Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. Our legal duty We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice. If you have any questions or complaints, please contact: Beth McCann, Patient Relations Director 1722 Shaffer Street, Suite 1, Kalamazoo, MI 49048 Phone: (269) 381-3963 ext. 408