833 MICHIGAN • SUITE 102

GRAND RAPIDS, MI 49503

(616) 459-8209 • FAX (616) 459-0313

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.

A. OUR COMMITMENT TO YOUR PRIVACY

Each time you visit our office or another health care provider contacts us concerning your medical needs, a record is made by our office. We are dedicated to maintaining the privacy of your record, which we will call “Protected Health Information” (PHI). We are required by law to give you this notice. It will tell you about the ways in which we may use your PHI and describes your rights and our obligations regarding the use and disclosure of that information.

We reserve the right to change this Notice of Privacy Practices and make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time. We are required by law to maintain the privacy of your PHI, to provide you with notice of our legal duties and privacy practices with respect to PHI, and to notify you following a breach of your unsecured PHI. We are required to abide by the terms of the Notice currently in effect.

B. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS

1. Treatment. We may use your PHI to provide medical services to you. Our staff involved in your care will have access to your PHI in order to treat you or to assist others in your treatment. We may also disclose your PHI to other health care providers for purposes related to your treatment, such as the pharmacy, laboratory or pathologist.

2. Payment. We may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to verify your coverage and we may provide your insurer with details regarding your treatment to determine if your insurer will pay for your treatment. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health Care Operations. We may review and use PHI in order to assess the office and make sure that your and our other patients receive quality care. For example, we may use your health information to evaluate the performance of our staff in caring for you. This information will then be used by us in an effort to continually improve the quality and effectiveness of our services.

4. Appointment Reminders and Information on Treatment Alternatives. We may contact you to provide appointment reminders, information concerning treatment alternatives or other health-related benefits and services that may be of interest to you.

5. Disclosures Required By Law. We will use and disclose your PHI when we are required to do so by federal, state or local law and the use or disclosure complies with and is limited to the requirements of the law.

6. Persons Involved in Your Care. We may disclose your health information that is directly relevant to your care to individuals you wish to receive such information, including family members, relatives, close personal friends, or other persons you identify. Before we do so, we will ask you, and follow your instructions, as to whether to make such disclosures, unless they are in the examination room with you.

C. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES

1. Public Health Risks and Health Oversight. We may disclose your PHI to public health authorities that are authorized by law to prevent or control disease, injury or disability; or to report deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products. We may disclosure your PHI to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights law and the health care system in general. We may disclose proof of immunization to a school where State or other law requires the school to have such information prior to admitting the student.
2. Lawsuits and Similar Proceedings. We may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
3. Law Enforcement. We may release PHI if asked to do so by a law enforcement official under certain circumstances: 1) regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement, 2) concerning a death we believe has resulted from criminal conduct, 3) regarding criminal conduct in our offices, 4) in response to a warrant, summons, court order, subpoena or similar legal process, 5) in an emergency to report a crime (including the location or victim of the crime, or the description, identity or location of the perpetrator.)
4. Deceased Patients. We may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
5. Serious Threats to Health or Safety. We may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
6. Military. We may disclose your PHI if you are a member of U.S. or foreign military forces including veterans and if required by the appropriate authorities.
7. National Security. We may disclose your PHI to federal officials for intelligence and nation security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
8. Inmates. We may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and (c) to protect your health and safety or the health and safety of other individuals.
9. Workers’ Compensation. We may release your PHI for workers’ compensation and similar programs.
10. Business Associates. Certain of our business operations may be performed by other businesses, referred to as “Business Associates.” We may need to disclose your PHI so that they can perform the job we’ve asked them to do. To protect you, we require our business associates to appropriately safeguard your health information.
11. Research Activities. In certain circumstances, we may use or provide PHI in order to conduct research. This research generally is subject to oversight by an institutional review board. In most cases, while PHI may be used to help prepare a research project or to contact you to ask whether you want to participate in a study, it will not be further disclosed for research without your authorization.
12. Applicable Michigan Law. Our use and disclosure of PHI must comply not only with federal privacy regulations but also with applicable Federal and Michigan law. Michigan law and Federal Regulations place certain additional restrictions on the use and disclosure of PHI for mental health, substance abuse, HIV/AIDS conditions, and certain genetic information. In some instances, your specific authorization may be required.
13. In certain circumstances, we must obtain your authorization to a use or disclosure of psychotherapy notes; for a use or disclosure of your PHI for marketing purposes; and for a disclosure of your PHI that is considered a sale resulting in remuneration to us.

D. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI that we maintain about you:
1. Confidential Communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work.

2. Requesting Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment or operations. This request must be made in writing. We are not required to agree to your restriction request. If we do agree, we will honor our agreement except in cases of an emergency or in cases where we are legally required or allowed to make a use or disclosure.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records. This does not include psychotherapy notes or information compiled in reasonable anticipation of certain civil, criminal or administrated proceedings.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request and amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to the privacy officer. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by us, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” This is a list of certain non- routine disclosures We have made of your PHI for non-treatment, non-payment or non-operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. We may charge you for the costs involved and you may withdraw your request before you incur any costs.

6. Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. This may be revoked at any time in writing after which, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with the practice’s privacy officer or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Receive a Paper Copy. You have the right to obtain a paper copy of this Notice from us upon request, even if you have agreed to receive this Notice electronically.

If you have any questions or concerns, or you wish to exercise any of the above rights please mail or deliver a signed letter detailing your request to our privacy officer, Gloria Merryman. We encourage you to call first at 616-459-1448, so that we can help you be as specific as possible with your request. We will promptly provide you with any forms needed to process your request.

Effective date of this Notice 9-23-13