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Notice and Acknowledgement
Acknowledgement:
I
acknowledge that I have received the attached Notice of Privacy Practices.
____________________________ _______________ Patient
or Personal Representative
Date Signature
If
Personal Representative’s signature appears above, please describe Personal
Representative’s relationship to the patient:
_____________________________________________________________
NOTICE
OF PRIVACY PRACTICES For
Asthma and
Allergy Associates, Sterling/Troy, P.C. (referred
to in this document as “the practice”)
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.
This Notice of Privacy Practices is being provided
to you as a requirement of the Health Insurance Portability and Accountability
Act (HIPAA). This Notice describes
how we may use and disclose your protected health information to carry
out treatment, payment or health care operations and for other purposes
that are permitted or required by law.
It also describes your rights to access and control your protected
health information in some cases. Your
"protected health information" means any of your written and
oral health information, including demographic data that can be used
to identify you. This is health information that is created
or received by your health care provider, and that relates to your past,
present or future physical or mental health or condition.
I. Uses and Disclosures of Protected
Health Information
The practice may use your protected health information
for purposes of providing treatment, obtaining payment for treatment,
and conducting health care operations. Your protected health information may be used or disclosed only
for these purposes unless the Practice has obtained your authorization
or the use or disclosure is otherwise permitted by the HIPAA Privacy
Regulations or State law. Disclosures
of your protected health information for the purposes described in this
Notice may be made in writing, orally, or by facsimile. A. Treatment. We will use and disclose
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 for treatment purposes.
For example, we may disclose your protected health information
to a pharmacy to fulfill a prescription, to a laboratory to order a
blood test, or to a home health agency that is providing care in your
home. We may also disclose protected health information to other physicians
who may be treating you or consulting with your physician with respect
to your care. In some cases,
we may also disclose your protected health information to an outside
treatment provider for purposes of the treatment activities of the other
provider. B. Payment. Your protected health information will be used, as needed, to obtain
payment for the services that we provide. This may include certain communications to your health insurer to
get approval for the treatment that we recommend. For example, if a hospital admission is recommended, we may need
to disclose information to your health insurer to get prior approval
for the hospitalization. We
may also disclose protected health information to your insurance company
to determine whether you are eligible for benefits or whether a particular
service is covered under your health plan.
In order to get payment for your services, we may also need to
disclose your protected health information to your insurance company
to demonstrate the medical necessity of the services or, as required
by your insurance company, for utilization review.
We may also disclose patient information to another provider
involved in your care for the other provider’s payment activities. C. Operations. We may use or disclose your protected health information, as necessary,
for our own health care operations in order to facilitate the function
of the practice and to provide quality care to all patients. Health care operations include such activities
as:
·
Quality assessment and improvement activities.
·
Employee review activities.
·
Training programs including those in which students, trainees, or
practitioners in health care learn under supervision.
·
Accreditation, certification, licensing or credentialing activities.
·
Review and auditing, including compliance reviews, medical reviews,
legal services and maintaining compliance programs.
·
Business management and general administrative activities.
In certain situations, we may also disclose patient information to
another provider or health plan for their health care operations.
D. Other Uses and Disclosures. As part of treatment, payment and healthcare operations,
we may also use or disclose your protected health information for the
following purposes:
·
To remind you of an appointment.
·
To inform you of potential treatment alternatives or options.
·
To inform you of health-related benefits or services that may be
of interest to you.
·
To contact you to raise funds for the practice or an institutional
foundation related to the practice.
If you do not wish to be contacted regarding fundraising, please
contact our Privacy Officer.
II.
Uses and Disclosures Beyond
Treatment, Payment, and Health Care Operations Permitted Without Authorization
or Opportunity to Object
Federal privacy rules allow us to use or disclose your protected
health information without your permission or authorization for a number
of reasons including the following:
A. When Legally Required. We will disclose your protected health information
when we are required to do so by any Federal, State or local law.
B. When
There Are Risks to Public Health.
We may disclose your protected health information for the following
public activities and purposes:
·
To prevent,
control, or report disease, injury or disability as permitted by law.
·
To report vital
events such as birth or death as permitted or required by law.
·
To conduct
public health surveillance, investigations and interventions as permitted
or required by law.
·
To collect
or report adverse events and product defects, track FDA regulated products,
enable product recalls, repairs or replacements to the FDA and to conduct
post marketing surveillance.
·
To notify a
person who has been exposed to a communicable disease or who may be
at risk of contracting or spreading a disease as authorized by law.
·
To report to
an employer information about an individual who is a member of the workforce
as legally permitted or required.
C. To Report Abuse,
Neglect Or Domestic Violence. We may notify
government authorities if we believe that a patient is the victim of
abuse, neglect or domestic violence.
We will make this disclosure only when specifically required
or authorized by law or when the patient agrees to the disclosure.
D. To Conduct Health
Oversight Activities. We may disclose your protected
health information to a health oversight agency for activities including
audits; civil, administrative, or criminal investigations, proceedings,
or actions; inspections; licensure or disciplinary actions; or other
activities necessary for appropriate oversight as authorized by law. We will not disclose your health information
if you are the subject of an investigation and your health information
is not directly related to your receipt of health care or public benefits.
E. In Connection With
Judicial And Administrative Proceedings. We may disclose your protected health information in the course
of any judicial or administrative proceeding in response to an order
of a court or administrative tribunal as expressly authorized by such
order or in response to a signed authorization (in a format approved
by the Michigan Court Administrator).
F. For Law Enforcement
Purposes. We may disclose your protected
health information to a law enforcement official for law enforcement
purposes as follows:
G. To Coroners, Funeral
Directors, and for Organ Donation. We may disclose protected health information to a coroner
or medical examiner for identification purposes, to determine cause
of death or for the coroner or medical examiner to perform other duties
authorized by law. 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 cadaveric organ, eye
or tissue donation purposes.
H. For Research Purposes. We may use or disclose
your protected health information for research when the use or disclosure
for research has been approved by an institutional review board or privacy
board that has reviewed the research proposal and research protocols
to address the privacy of your protected health information.
I. In the Event of
A Serious Threat To Health Or Safety. We may, consistent
with applicable law and ethical standards of conduct, use or disclose
your protected health information if we believe, in good faith, that
such use or disclosure is necessary to prevent or lessen a serious and
imminent threat to your health or safety or to the health and safety
of the public.
J. For Specified Government
Functions. In certain circumstances, the
Federal regulations authorize the practice to use or disclose your protected
health information to facilitate specified government functions relating
to military and veterans activities, national security and intelligence
activities, protective services for the President and others, medical
suitability determinations, correctional institutions, and law enforcement custodial situations.
K. For Worker's Compensation. The practice may release your
health information to comply with worker's compensation laws or similar
programs.
III.
Uses and Disclosures Permitted
Without Authorization But With Opportunity to Object
We may disclose your protected health
information to your family member or a close personal friend if it is
directly relevant to the person’s involvement in your care or payment
related to your care. We can
also disclose your information in connection with trying to locate or
notify family members or others involved in your care concerning your
location, condition or death.
You may
object to these disclosures. If
you do not object to these disclosures or we can infer from the circumstances
that you do not object or we determine, in the exercise of our professional
judgment, that it is in your best interests for us to make disclosure
of information that is directly relevant to the person’s involvement
with your care, we may disclose your protected health information as
described.
IV. Uses and Disclosures Which You Authorize
Other than as stated above, we will not disclose your
health information other than with your written authorization. You may revoke your authorization in writing
at any time except to the extent that we have taken action in reliance
upon the authorization.
V. Your Rights
You have the following rights regarding your health
information: A. The right to inspect and copy your
protected health information. You may inspect and obtain a copy of your protected
health information 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 and any other records that your physician and the
practice 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 for use in, a
civil, criminal, or administrative action or proceeding; and protected
health information that is subject to a law that prohibits access to
protected health information. Depending
on the circumstances, you may have the right to have a decision to deny
access reviewed. We may deny your request to inspect or copy your protected health
information if, in our professional judgment, we determine that the
access requested is likely to endanger your life or safety or that of
another person, or that it is likely to cause substantial harm to another
person referenced within the information.
You have the right to request a review of this decision. To
inspect and copy your medical information, you must submit a written
request to the Privacy Officer whose contact information is listed on
the last pages of this Notice. If
you request a copy of your information, we may charge you a fee for
the costs of copying, mailing or other costs incurred by us in complying
with your request. Please contact our Privacy Officer if you have questions about access
to your medical record. B. The right to request a restriction
on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected
health information for the purposes of treatment, payment or health
care operations. You may also
request that we not disclose your health information 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 state the specific restriction requested and
to whom you want the restriction to apply. The practice is not required to agree to a restriction that you may
request. We will notify you
if we deny your request to a restriction.
If the practice 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.
Under certain circumstances, we may terminate our agreement to
a restriction. You may request
a restriction by contacting the Privacy Officer. C. The right to request to receive
confidential communications from us by alternative means or at an alternative
location. You have the right to request
that we communicate with you in certain ways. We will accommodate reasonable requests. We may 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 require you to provide an explanation for your request.
Requests must be made in writing to our Privacy Officer. D. The right to have your physician
amend your protected health information. 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 will provide you with a copy of any such rebuttal.
Requests for amendment must be in writing and must be directed
to our Privacy Officer. In this
written request, you must also provide a reason to support the requested
amendments. E. The right to receive an accounting. You have the right to request an accounting
of certain disclosures of your protected health information made by
the practice. This
right applies to disclosures for purposes other than treatment, payment
or health care operations as described in this Notice of Privacy Practices. We are also not required to account for disclosures
that you requested, disclosures that you agreed to by signing an authorization
form, disclosures for a facility directory, to friends or family members
involved in your care, or certain other disclosures we are permitted
to make without your authorization.
The request for an accounting must be made in writing to our
Privacy Officer. The request should specify the time period
sought for the accounting. We
are not required to provide an accounting for disclosures that take
place prior to April 14, 2003. Accounting
requests may not be made for periods of time in excess of six years. We will provide the first accounting you request
during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based
fee. F. The right to obtain a paper copy
of this notice. Upon request, we will provide
a separate paper copy of this notice even if you have already received
a copy of the notice or have agreed to accept this notice electronically.
VI. Our Duties The
practice is required by law to maintain the privacy of your health information
and to provide you with this Notice of our duties and privacy practices. We are required to abide by terms of this Notice
as may be amended from time to time.
We reserve the right to change the terms of this Notice and to
make the new Notice provisions effective for all protected health information
that we maintain. If the practice
changes its Notice, we will provide a copy of the revised Notice by
sending a copy of the Revised Notice via regular mail or through in-person
contact. VII.
Complaints You
have the right to express complaints to the practice and to the Secretary
of Health and Human Services if you believe that your privacy rights
have been violated. You may
complain to the practice by contacting the practice’s Privacy Officer
verbally or in writing, using the contact information below.
We encourage you to express any concerns you may have regarding
the privacy of your information. You
will not be retaliated against in any way for filing a complaint. VIII. Contact Person
The practice’s contact person for all issues regarding
patient privacy and your rights under the Federal privacy standards
is the Privacy Officer. Information
regarding matters covered by this Notice can be requested by contacting
the Privacy Officer. Complaints
against the practice, can be mailed to the Privacy Officer by sending
it to:
Allergy and Asthma Associates, Sterling/Troy, P.C. 2950 East Wattles Road, Suite 300 Troy, MI 48085 ATTN: Privacy
Officer
The Privacy Officer can be contacted by telephone at
248-524-2121
IX. Effective Date
This Notice is effective April 14, 2003.
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