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NOTICE
OF PRIVACY PRACTICES
For
A.
JAMES POTTER, M.D.
(referred to in this document as "the provider")
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
provider 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 Provider 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 provider 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 provider or an institutional
foundation related to the provider.
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 subpoena in some
circumstances.
F.
For Law Enforcement Purposes.
We may disclose your protected health information to a
law enforcement official for law enforcement purposes as
follows:
- As required by law for
reporting of certain types of wounds or other physical
injuries.
- Pursuant to court order,
court-ordered warrant, subpoena, summons or similar
process.
- For the purpose of
identifying or locating a suspect, fugitive, material
witness or missing person.
- Under certain limited
circumstances, when you are the victim of a crime.
- To a law enforcement
official if the provider has a suspicion that your death
was the result of criminal conduct.
- In an emergency in order
to report a crime.
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 provider 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 provider 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 provider 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
provider 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 provider 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 provider.
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
provider 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 provider 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 provider and to the
Secretary of Health and Human Services if you believe that your
privacy rights have been violated.
You may complain to the provider by contacting the
provider’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
provider’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 provider can be mailed to the
Privacy Officer by sending it to:
A.JamesPotter,M.D..
1675 Leahy Street, Suite 315
Muskegon,
Michigan 49442
ATTN: Privacy Officer
The
Privacy Officer can be contacted by telephone at 231.728.3344
IX.
Effective Date
This
Notice is effective April 14, 2003.
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