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. THE PRIVACY OF YOUR MEDICAL INFORMATION
IS IMPORTANT TO US.
Overview
The law requires us to keep your protected health information
(“PHI”) private in accordance with this Notice of
Privacy Practices (“Notice”), as long as this Notice
remains in effect. We are also required to provide you with a
paper copy of this Notice, which contains our privacy practices,
our legal duties, and your rights concerning your PHI.
From time to time, we may revise our privacy practices and the
terms of our Notice, as permitted or required by applicable law.
Such revisions to our privacy practices and our Notice may be
retroactive. Our revised Notice will be made available to our
patients prior to any significant revisions of our privacy practices
and policies.
Our Privacy Practices
Use and Disclosure. We may use or disclose your
PHI for treatment, payment, or health care operations. For your
convenience, we have provided the following examples of such potential
uses or disclosures:
Treatment. Your PHI may be used by or disclosed
to any physicians or other health care providers involved with
the medical services provided to you.
Payment. Your PHI may be used or disclosed
in order to collect payment for the medical services provided
to you.
Health Care Operations. Your PHI may be used
or disclosed as part of our internal health care operations.
Such health care operations may include, among other things,
quality of care audits of our staff and affiliates, conducting
training programs, accreditation, certification, licensing,
or credentialing activities.
Authorizations. We will not use or disclose
your medical information for any reason except those described
in this Notice, unless you provide us with a written authorization
to do so. We may request such an authorization to use or disclose
your PHI for any purpose, but you are not required to give us
such authorization as a condition of your treatment. Any written
authorization from you may be revoked by you in writing at any
time, but such revocation will not affect any prior authorized
uses or disclosures.
Patient Access. We will provide you with access
to your PHI, as described below in the Individual Rights section
of this Notice. With your permission, or in some emergencies,
we may disclose your PHI to your family members, friends, or other
people to aid in your treatment or the collection of payment.
A disclosure of your PHI may also be made if we determine it is
reasonably necessary or in your best interests for such purposes
as allowing a person acting on your behalf to receive filled prescriptions,
medical supplies, X rays, etc.
Locating Responsible Parties. Your PHI may
be disclosed in order to locate, identify or notify a family member,
your personal representative, or other person responsible for
your care. If we determine in our reasonable professional judgment
that you are capable of doing so, you will be given the opportunity
to consent to or to prohibit or restrict the extent or recipients
of such disclosure. If we determine that you are unable to provide
such consent, we will limit the PHI disclosed to the minimum necessary.
Disasters. We may use or disclose your PHI
to any public or private entity authorized by law or by its charter
to assist in disaster relief efforts.
Required by Law. We may use or disclose your
medical information when we are required to do so by law. For
example, your PHI may be released when required by privacy laws,
workers' compensation or similar laws, public health laws, court
or administrative orders, subpoenas, certain discovery requests,
or other laws, regulations or legal processes. Under certain circumstances,
we may make limited disclosures of PHI directly to law enforcement
officials or correctional institutions regarding an inmate, lawful
detainee, suspect, fugitive, material witness, missing person,
or a victim or suspected victim of abuse, neglect, domestic violence
or other crimes. We may disclose your PHI to the extent reasonably
necessary to avert a serious threat to your health or safety or
the health or safety of others. We may disclose your PHI when
necessary to assist law enforcement officials to capture a third
party who has admitted to a crime against you or who has escaped
from lawful custody.
Deceased Persons. After your death, we may
disclose your PHI to a coroner, medical examiner, funeral director,
or organ procurement organization in limited circumstances.
Military and National Security. We may disclose
to military authorities the medical information of Armed Forces
personnel under certain circumstances. When required by law, we
may disclose your PHI for intelligence, counterintelligence, and
other national security activities.
Your Individual Rights
Access and Copies. In most cases, you have the
right to review or to purchase copies of your PHI by requesting
access or copies in writing to our Privacy Officer. Please contact
our Privacy Officer regarding our copying fees.
Disclosure Accounting. You have the right to
receive an accounting of the instances, if any, in which your
PHI was disclosed for purposes other than those described in the
following sections above: Use and Disclosures, Patient Access,
and Locating Responsible Parties. For each 12-month period, you
have the right to receive one free copy of an accounting certain
details surrounding such disclosures that occurred after April
13, 2003. If you request a disclosure accounting more than once
in a 12-month period, we will charge you a reasonable, cost-based
fee for each additional request. Please contact our Privacy Officer
regarding these fees.
Additional Restrictions. You have the right
to request that we place additional restrictions on our use
or disclosure of your PHI, but we are not required to honor
such a request. We will be bound by such restrictions only if
we agree to do so in writing signed by our Privacy Officer.
Alternate Communications. You have the right
to request that we communicate with you about your PHI by alternative
means or in alternative locations. We will accommodate any reasonable
request if it specifies in writing the alternative means or
location, and provides a satisfactory explanation of how future
payments will be handled.
Amendments to PHI. You have the right to
request that we amend your PHI. Any such request must be in
writing and contain a detailed explanation for the requested
amendment. Under certain circumstances, we may deny your request
but will provide you a written explanation of the denial. You
have the right to send us a statement of disagreement to which
we may prepare a rebuttal, a copy of which will be provided
to you at no cost. Please contact our Privacy Officer with any
further questions about amending your medical record.
Complaints
If you believe we have violated your privacy rights, you may
file a complaint with us by notifying our Privacy Officer. We
support your right to protect the privacy of your medical information.
We will not retaliate in any way if you choose to file a complaint
with us or with the Secretary of the U.S. Department of Health
and Human Services.
Privacy Officer
Barbara Bowman
42755 Mound Road, Sterling Heights, MI. 48314
Phone (586) 323-0400 • Fax (586) 323-3761
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