Patient Privacy
Patient Privacy

ANCHOR BAY CLINIC FAMILY MEDICAL CENTER, P.C.

 

NOTICE OF PRIVACY PRACTICES

 

Effective Date: December 1, 2012


Contents

 

Introduction..................................................................................................................................... 1

Definitions....................................................................................................................................... 1

Uses and Disclosures..................................................................................................................... 2

Treatment, Payment and Healthcare Operations.......................................................................... 2

Treatment....................................................................................................................................... 2

Payment......................................................................................................................................... 2

Healthcare Operations.................................................................................................................... 2

Disclosures to You.......................................................................................................................... 2

Appointments.................................................................................................................................. 2

Other Covered Entities................................................................................................................... 2

Friends and Family......................................................................................................................... 3

Notification...................................................................................................................................... 3

Business Associates....................................................................................................................... 3

Public Policy................................................................................................................................... 3

Required by Law............................................................................................................................. 3

Public Health Activities................................................................................................................... 3

Law Enforcement .......................................................................................................................... 4

Decedents....................................................................................................................................... 4

Cadaveric Organ, Eye or Tissue Donation.................................................................................... 4

Threats to Health or Safety............................................................................................................ 4

Governmental Functions................................................................................................................ 4

Workman’s Compensation............................................................................................................. 4

Disclosures to the Secretary of the U.S. Department of Health and Human Services................. 4

Research ....................................................................................................................................... 4

Other Uses and Disclosures of Your Protected Health Information.............................................. 5

Your Rights..................................................................................................................................... 5

Right to Notice ............................................................................................................................... 5

Right to Request Restrictions......................................................................................................... 5

Right to Confidential Communications .......................................................................................... 6

Right of Access to PHI................................................................................................................... 6

Right to Amend PHI........................................................................................................................ 6

Right to an Accounting of PHI Disclosures.................................................................................... 6

Our Duties....................................................................................................................................... 7

Contact Information, Questions and Further Information.............................................................. 7

Complaints...................................................................................................................................... 7


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.

Anchor Bay Clinic Family Medical Center, P.C. (“Anchor Bay Clinic”) is committed to providing quality health care service to you. An important part of that is protecting your medical information according to applicable law. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose your protected health information (“PHI”), your rights and our duties concerning your PHI under Federal Law, as well as other pertinent information, and was drafted in accordance with the HIPAA Privacy Rule, contained in the Code of Federal Regulations at 45 CFR Parts 160 and 164. We are happy to answer any questions you may have regarding this Notice. Upon your request, our staff will briefly review the key points contained herein once you have had an opportunity to read and sign.

DEFINITIONS

1.    “Healthcare Operations” means business activities that we engage  in so as to provide healthcare services to you, including but not limited  to, quality assessment and improvement activities, personnel training and evaluation, business planning and development,  and other administrative and managerial functions.

 

2.    “Payment” means activities that we undertake as a healthcare provider to obtain reimbursement for the provision of healthcare to you which include, but are not limited to: determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and processing health benefit claims.

 

3.    “Protected  Health Information” or “PHI” means information which identifies you (e.g. name, address, social security number, etc.) and relates to your past, present,  or future physical or mental health or condition; the provision of healthcare to you; or the past, present, or future  payment for the provision of healthcare to you.

 

4.    “Treatment” means the provision, coordination, or management of healthcare and related services on your behalf, including the coordination or management of healthcare with a third party; consultation between Anchor Bay Clinic and other healthcare providers relating to your care; or the referral by Anchor Bay Clinic of your care to another healthcare provider.

USES AND DISCLOSURES

Uses and disclosures of your PHI may be permitted, required, or authorized. Examples are provided below under various categories to give you a sense of how we may use and/or disclose your PHI.

Treatment, Payment and Healthcare Operations

We will use and disclose your PHI as follows: 1) to ensure that we appropriately provide for your care and Treatment; 2) to obtain Payment for our services; and 3) as necessary to conduct our Healthcare Operations.

Treatment.  Our staff, including doctors, nurses and other clinicians, will use your PHI to order tests, procedures, and medications; and to otherwise provide for your care. We may disclose your PHI to pharmacies and other healthcare providers as needed. For example, we may disclose your PHI when we refer you to another healthcare provider.

Payment.  Your PHI will be used to check for eligibility for insurance coverage and prepare claims for your insurance company where appropriate. We may also use your PHI to invoice you directly or to invoice a government agency on your behalf. For example, in order to prepare invoices, we will disclose information regarding your treatment, the conditions you were treated for, and when you were treated.

Healthcare Operations.  We may use and disclose your PHI in order to conduct our healthcare business and to perform functions associated with our business activities. For example, your PHI may be disclosed when we train staff, conduct quality improvement activities, and develop business plans. Your PHI may also be shared with business associates who perform certain business functions on our behalf such as billing, transcriptions and electronic PHI transmissions with other healthcare providers.

Disclosures to You

Anchor Bay Clinic is required to disclose to you or your personal representative most of your PHI when you request access to this information. Anchor Bay Clinic will disclose your PHI to an individual who has been designated by you as your personal representative and who has qualified for such designation in accordance with relevant law. Prior to such a disclosure, however, Anchor Bay Clinic must be given written documentation that supports and establishes the basis for the personal representation. Anchor Bay Clinic may elect not to treat the person as your personal representative if it has a reasonable belief that you have been, or may be, subjected to domestic violence, abuse, or neglect by such person; that treating such person as your personal representative could endanger you; or if Anchor Bay Clinic determines, in the exercise of its professional judgment, that it is not in your best interest to treat the person as your personal representative.

 

Appointments

We may use your PHI to contact you regarding appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Other Covered Entities

Anchor Bay Clinic may use or disclose your PHI to assist health care providers in connection with their treatment or payment activities, or to assist other covered entities in connection with certain health care operations. For example, Anchor Bay Clinic may disclose your PHI to a health care provider when needed by the provider to render treatment to you, and Anchor Bay Clinic may disclose PHI to another covered entity to conduct health care operations in the areas of quality assurance and improvement activities, or accreditation, certification, licensing, or credentialing. This also means that Anchor Bay Clinic may disclose or share your PHI with other health care programs or insurance carriers (such as Medicare, Blue Cross Blue Shield, etc.) in order to coordinate benefits, if you or your family members have other health insurance or coverage.

Friends and Family

We may disclose your PHI to friends and family who are involved in or responsible for your care unless you object or request a restriction on disclosure of PHI to any of these individuals.  For example, we will request that you grant us express permission before discussing your PHI in the company of friends and family. If you elect not to proceed, then friends and family will be excluded from any such conversation. In emergency circumstances, or if you are not present to agree or object, then we will use our professional judgment regarding those communications.

Notification

We may use or disclose your PHI to notify, or assist in the notification of (including identifying or locating), a family member, a personal representative, or another person responsible for your care. Any such use or disclosure of your PHI for notification purposes will be made consistent with this policy and applicable law. For example, such notification will only proceed with your permission if you have the capacity to grant it, otherwise the required notification will be guided by our professional judgment.

Business Associates

We may use or disclose your PHI without your consent or authorization to a business associate that performs a business function (for example, billing) on our behalf and may need to receive, create, maintain, use or disclose your PHI in order to do so. Such use or disclosure will only occur after performing due diligence to ensure that the business associate is meeting all statutory and contractual requirements. A written contract requiring business associate to appropriately safeguard your PHI will be executed with each business associate.

Public Policy and Other Uses and Disclosures

 

There are a number of uses and disclosures that we are required or permitted to make for public policy, as may be required by federal, state, or local law, and other reasons without your consent or authorization. The following is a representative list of uses and disclosures that fall under this category.

 

Required by Law.  We may use or disclose your PHI to the extent that such use or disclosure is required by law. In such cases, the use or disclosure will be limited to uses and disclosures pertaining to the relevant requirements of such law.

Public Health Activities.  We may disclose your PHI to governmental authorities for public health activities and for purposes described as follows:

1)     preventing or controlling disease, injury, or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth or death, and the conduct of public health surveillance, public health investigations, and public health interventions; or, at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority;

 

2)     reporting child abuse or neglect;

 

3)     activities related to the quality, safety or effectiveness of a Food and Drug Administration regulated  product or process;

 

4)     to persons who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if we are authorized by law to notify such persons as necessary in the conduct of a public health intervention or investigation; or

 

5)     to an employer, about an individual  who is a member of the workforce of the employer, under a limited set of conditions.

 

Law Enforcement.  We may disclose your PHI for law enforcement purposes to a law enforcement official, but only for law enforcement purposes and if certain specified conditions are met. For example, we may disclose your PHI to law enforcement for purposes of identification and for purposes related to a crime.

 

Decedents.  We may disclose PHI to a coroner, medical examiner or funeral director for the purpose of identifying a deceased person, determining a cause of death, or otherwise carrying out their duties as authorized by law.

 

Cadaveric Organ, Eye or Tissue Donation.  We may disclose PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.

 

Threats to Health or Safety.  We may, consistent with applicable law and standards of ethical conduct, use or disclose your PHI if we have a good faith belief 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 or is required by law enforcement authorities to identify or apprehend an individual.

 

Governmental Functions.  We may use or disclose your PHI for the following governmental functions as long as certain specified conditions are met: 1) military and veterans activities; 2) national security and intelligence activities; 3) protective services for the President and others; 4) medical suitability determinations for a covered entity that is a component of the Department of State; 5) correctional  institutions and other law enforcement  custodial situations; and 6) covered entities that are government  programs providing public benefits.

 

Workman's Compensation.  We may disclose your PHI as authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs,  established by law, that provide benefits for work-related injuries or illness without regard to fault.

 

Disclosures to the Secretary of the U.S. Department of Health and Human Services.  Anchor Bay Clinic is required to disclose your PHI to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining Anchor Bay Clinic’s compliance with the HIPAA Privacy Rule.

 

Research.  We may use or disclose your PHI for research provided that certain  conditions are met, including but not limited to the approval of research by an Institutional Review Board and consistent with applicable law, or where research involves a limited data set which includes no unique identifiers (such as name, address, social security number, etc. that can identify you).

 

OTHER USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

 

Other uses and disclosures of your PHI that are not described above will be made only with your written authorization.  Also, under certain circumstances, we may only use and disclose your PHI with your authorization as directly provided by you, or in a context wherein we can reasonably infer it, unless you are not present, are incapacitated, or an emergency exists, in which case we are compelled by law to use our professional judgment to determine when to use your PHI, and the extent to which it is used. If you provide Anchor Bay Clinic with an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of PHI. However, the revocation will not be effective for information that Anchor Bay Clinic has used or disclosed in reliance on the authorization. The following are examples of when you will have an opportunity to agree or object.

YOUR RIGHTS

 

Federal law provides you several important rights regarding your PHI. The following sections summarize your rights and provide information regarding how to exercise them.  Protecting your PHI is an important part of the services we provide you. We want to ensure that you have access to your PHI when you need it and that you clearly understand your rights as described below.

 

Right to Notice

 

You have a right to adequate notice of the uses and disclosures of your PHI, and our duties and responsibilities regarding same, as provided for herein. You have a right to request both a paper and electronic copy of this Notice.

 

Right to Request Restrictions

 

You have a right to request restrictions on how we use and disclose your PHI for treatment, payment and healthcare operations, as well as regarding those instances where you have an opportunity to agree or object. You also have a right to request a limit on disclosures of your PHI to family members or friends who are involved in your care or the payment for your care. Your request must include the PHI you wish to limit, whether you want to limit Anchor Bay Clinic’s use, disclosure, or both, and (if applicable), to whom you want the limitations to apply (for example, disclosures to your spouse).  You may request such a restriction using the Contact Information at the end of this Notice. We are not required to agree to restrictions for treatment, payment and operations except in limited circumstances. If we do agree to a restriction of any kind then we will honor it going forward, unless you take affirmative steps to revoke it or we believe, in our professional  judgment, that an emergency warrants circumventing the restriction  in order to provide the appropriate care.  If restricted PHI is disclosed to a health care provider for emergency treatment, Anchor Bay Clinic shall request that such health care provider not further use or disclose the information. Anchor Bay Clinic may terminate its agreement to a restriction if 1) you agree to or request the termination in writing, 2) you orally agree to the termination and the oral agreement is documented; 3) or Anchor Bay Clinic notifies you that it is terminating its agreement to a restriction, except that such termination is only effective with respect to PHI created or received after it provided such notice. In rare circumstances, we reserve the right to terminate a restriction that we have previously agreed to, but only after providing you notice of termination.

 

Right to Confidential Communications

 

You have a right to request alternative communication methods with respect your health matters and related PHI. You must request a confidential communication in writing, using the Contact Information at the end of this Notice. Your request must specify the alternative means or location for communication with you. Anchor Bay Clinic will accommodate all reasonable requests for confidential communications, but may condition it on, when appropriate, information as to how payment, if any, will be handled.

 

Right of Access to PHI

 

You have a right to access a copy of your PHI except where excluded by applicable law. All requests for access to your PHI must be made in writing to the Contact Information at the end of this Notice. Under a limited set of circumstances, we may deny your request. Any denial of a request to access will be communicated to you in writing. In general, you have a right to have a denial reviewed by a licensed third party healthcare professional (i.e. one not affiliated with us). We will comply with the decision made by the designated professional. We may charge you a reasonable fee for providing you a copy of your PHI.

 

Note that under Federal law, 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 PHI that is subject to law that prohibits access to PHI.

 

Right to Amend PHI

 

You have a right to request that we amend your PHI for as long as it is maintained by us if you believe that information is incorrect or incomplete. The request must be made in writing, using the Contact Information at the end of this Notice, and you must provide a reason to support the requested amendment.  Under certain conditions we may deny your request to amend, including but not limited to, when the PHI: 1) was not created by us; 2) is excluded from access and inspection under applicable law; or 3) is accurate and complete. If Anchor Bay Clinic denies your request, you have the right to file a statement of disagreement. Your statement of disagreement will be linked with the disputed information and all future disclosures of the disputed information will include your statement. If we accept the amendment we will work with you to identify other healthcare stakeholders that require notification and provide the notification. If we deny the amendment, we will provide the rationale for denial to you in writing and afford you the opportunity to submit a statement of disagreement.

 

Right to an Accounting of PHI Disclosures

 

You have right to receive an accounting of your PHI disclosures made by us during a time period specified by applicable law (generally, 6 years with some exceptions for electronic medical records) prior to the date on which the accounting is requested. You must make any request for an accounting in writing to the contact information at the end of this Notice. Certain PHI is excluded from an accounting by law and therefore will not be provided. One accounting within any twelve (12) month period will be provided to you at no charge. Additional accountings within the same twelve (12) month period may require that you pay us a reasonable fee. We will notify you of the fee to be charged (if any) at the time of the request, and you may choose to withdraw or modify your request before any costs are incurred.

 

OUR DUTIES

 

We are required to law: 1) maintain the privacy of your PHI; 2) provide you with this Notice setting forth our legal duties and privacy practices with respect to your PHI; 3) abide by the terms of the Notice currently in effect; and 4) modify this Notice when there are material changes to your rights, our duties, or other practices contained herein. This Notice will remain in effect until it is revised.

 

We reserve the right to change our privacy practices and the terms of this Notice at any time consistent with applicable law and our current business processes. Should we make material revisions to this Notice, we will provide you notification as follows: 1) upon request; 2) electronically via our website or via other electronic communications; 3) as posted in our place of business; and 4) provide a copy to you during your next visit to our office.  Any modifications to our Notice may apply retroactively to your entire PHI, as maintained by us.

 

In addition to the above, we have an affirmative duty to respond to your requests (i.e. those corresponding to your rights) in a timely and appropriate manner. We support and value your right to privacy and are committed to maintaining reasonable and appropriate safeguards for your PHI. We will not retaliate in any way shape or form should you decided to file a complaint with us or with the Department of Health and Human Services.

 

CONTACT INFORMATION, QUESTIONS AND FURTHER INFORMATION

 

To exercise any of the rights described in this Notice and for questions, requests for information, complaints, and other inquiries under this Notice, or the policies and procedures described in this Notice, please contact us as follows:

 

Anchor Bay Clinic Family Medical Center, P.C.

32901 23 Mile Road, Suite 100

Chesterfield, MI 48047

Phone 586 725-8500 X 110

Fax 586 725-8500

ATTN:  Irene Scott, Privacy Official

 

Complaints

 

If you believe that your rights have been violated, then you may submit a formal written complaint to us using the Contact Information provided above.  You may also send a written complaint directly to the Department of Health and Human Services (“HHS”) by using its Health Information Privacy Complaint Package. If you have questions regarding how to file a complaint with HHS you may contact the agency via email at OCRMail@hhs.gov or visit the IIIIS website at www.hhs.gov. 

 

Effective Date: ______________________, 20__