NOTICE OF PRIVACY PRACTICES
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.
(Click here for a printable version.)
Effective Date: April 14, 2003
If you have any questions about this notice, please contact our Medical Information Supervisor by telephone at (231) 924-4200, or in person or in writing at 230 West Oak Street, Fremont, MI 49412.
YOUR HEALTH INFORMATION
Pine Medical Group, P.C. is committed to preserving the privacy and confidentiality of your health information that is created and/or maintained at our clinic. State and federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your health information. This notice will provide you with information regarding our privacy practices and applies to all of your health information created and/or maintained at our clinic, including any information that we received from other health care providers or facilities. Protected Health Information, or PHI, is any information, whether oral or recorded in any form that: A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and B) relates to the past, present, or future physical or mental health condition of an individual; the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual. This notice describes the ways in which we may use or disclose your health information and also describes your rights and our obligations concerning such uses and disclosures.
We are required by law to maintain the privacy of PHI and to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We will abide by the terms of this notice, including any future revisions that we may make to the notice as required or authorized by law. We reserve the right to change is notice and to make the revised or changed notice effective for health information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice, which will identify its effective date, in our waiting area.
WHO WILL FOLLOW THIS NOTICE
The privacy practices described in this notice will be followed by:
• Any health care professional authorized to enter information into your medical chart created and/or maintained at our clinic;
• All employees, students, residents, and other services providers who have access to your health information at our clinic; and
• Any member of a volunteer group that is allowed to help you while receiving services at our clinic.
The individuals identified above will share your health information with each other for purposes of treatment, payment, and health care operations, as further described in this notice.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.
For example, your doctor may be treating you for a heart condition and may need to know if you have other health problems that could complicate your treatment. The doctor may use your medical history to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the most appropriate care for you.
Different personnel in our office may disclose information about you to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering x rays. Other health care providers and designated family members may be part of your medical care outside this office and may require information about you that we have.
For Payment We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a service you received so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine if your plan will pay for the treatment.
For Health Care Operations We may, within our office, use and disclose health information about you in order to conduct our normal operations. Examples of normal operations include but are not limited to :
• Quality assurance activities
• Evaluation of staff performance in caring for you
• Evaluate the effectiveness of treatments and services
• Various business functions
USES AND DISCLOSURES IN SPECIAL SITUATIONS
We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:
Appointment Reminders We may use or disclose your health information for purposes of contacting you as a reminder that you have an appointment for treatment or medical care at the office. Unless otherwise directed, messages may be left on your telephone answering machine or with a family member. Please notify us in writing if you do not wish to be contacted for appointment reminders.
Treatment Alternatives and Health-Related Products and Services We may use or disclose your health information for purposes of contacting you to inform you of treatment alternatives or health-related products or services that may be of interest to you. For example, if you are diagnosed with a diabetic condition, we may contact you to inform you of a diabetic instruction class that we offer at our clinic.
To Avert a Serious Threat to Health or Safety We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required By Law We will disclose health information about you when required to do so by federal, state or local law.
Research We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are or if the researcher is involved in your care at the office.
Organ and Tissue Donation If you are an organ donor we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank as necessary to facilitate such donation and transplantation.
Military, Veterans, National Security and Intelligence If you are a member of the armed forces, we may use or disclose your health information as required by military command authorities or authorized federal officials for purposes of intelligence, counterintelligence, and other national security activities as authorized by law. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work related injuries or illness.
Public Health Activities We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs and compliance with civil rights laws.
Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
Divorce, Legal Separation, Legal Guardianship, Custody Disputes, Foster Children, and Restraining Orders We will do our best to only release health information to persons with legal rights in the case of minors. If a dispute or suspicion arises, parties involved may be required to produce court documents indicating proof of the arrangements which have been made to protect the minor's health information.
Law Enforcement We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may use or disclose your health information to the correctional institution or to the law enforcement official as may be necessary: 1) for the institution to provide you with health care; 2) to protect the health or safety of you or another person; or 3) for the safety and security of the correctional institution.
Coroners, Medical Examiners and Funeral Directors We may release health information 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 your health information to a funeral director for the purpose of carrying out his/her necessary activities.
Information Not Personally Identifiable We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends We may disclose your health information to individuals, such as family members and friends, who are involved in your care or who help pay for your care. We may make such disclosures when: (a) we have your verbal or written agreement to do so; (b) we make such disclosures and you do not object; or (c) we can infer from the circumstances that you would not object to such disclosures. For example, if your spouse comes into the exam room with you, we will assume that you agree to our disclosure of your information while your spouse is present in the room.
We may also disclose your health information to family members or friends in instances when you are unable to agree or object to such disclosures, provided that we feel it is in your best interests to make such disclosures and the disclosures relate to that family member or friend's involvement in your care. For example, if you present to our clinic with an emergency medical condition, we may share information with the family member or friend that comes with you to our clinic. We also may share your health information with a family member or friend who calls us to request a prescription refill for you.
OTHER USES AND DISCLOSURES PURSUANT TO YOUR WRITTEN AUTHORIZATION
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose health 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 information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures which were already made with your permission.
If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization (different than the Authorization mentioned prior) from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have a special written authorization that complies with the law governing HIV or substance abuse records.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Inspect and/or Copy You have the right to inspect and/or copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to our Medical Information Supervisor in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If you request a denial be reviewed, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. To request an amendment, complete and submit a Medical Record Amendment/Correction Form to the Medical Information Supervisor.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
• We did not create
• Is not part of the health information that we keep
• You would not be permitted to inspect and copy
• Is accurate and complete
Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must fill out a Request for Accounting of Disclosures form and submit it to the Medical Information Supervisor. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Our practice is to respond to such a request within 30 days.
Right to Request Restrictions You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you may complete and submit the Request For Restriction On Use/Disclosure Of Medical Information to the Medical Information Supervisor.
Right to Request Confidential Communications You have the right to request that we communicate with you about your health care in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you may complete and submit the Request For Restriction On Use/Disclosure Of Medical Information And/Or Confidential Communication to the Medical Information Supervisor. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, make your request at our registration area or contact the Medical Information Supervisor at (231) 924-4200.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. The revised or changed notice is effective for medical information we already have about you as well as any information we receive in the future. We will post a current notice in the office with its effective date on the front page. You are entitled to a copy of the notice currently in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact the Medical Information Supervisor by telephone at (231) 924-4200, or in person or writing at 230 West Oak Street, Fremont, MI 49412. You will not be penalized for filing a complaint.
