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Notice of Privacy Practices
Alternative Health Care Center
20415 Mack Ave.
Grosse Pointe Woods, MI 48236- 1660
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. If you have any questions about this Notice
please contact: our Privacy Contact who is Rochelle.
This Notice of Privacy Practices 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. "Protected health information" is information about
you, including demographic information, that may identify you and that relates
to your past, present or future physical or mental health or condition and
related health care services.
We are required to abide by the terms of this Notice of Privacy Practices.
We may change the terms of our notice, at any time. The new notice will be
effective for all protected health information that we maintain at that
time. Upon your request, we will provide you with any revised Notice of
Privacy Practices by accessing our website
www.ahccenter.com,
calling the office and requesting that a revised copy be sent to you in the mail
or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information Based Upon Your Written
Consent
You will be asked by your physician to sign a consent form. Once you have
consented to use and disclosure of your protected health information for
treatment, payment and health care operations by signing the consent form, your
physician will use or disclose your protected health information as described in
this Section 1. Your protected health information may be used and
disclosed by your physician, our office staff and others outside of our office
that are involved in your care and treatment for the purpose of providing health
care services to you. Your protected health information may also be used
and disclosed to pay your health care bills and to support the operation of the
physicians practice.
Following are examples of the types of uses and disclosures of your protected
health care information that the physicians office is permitted to make once you
have signed our consent form. These examples are not meant to be
exhaustive, but to describe the types of uses and disclosures that may be made
by our office once you have provided consent.
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 that has already obtained your permission to have access to
your protected health information. For example, we would disclose your
protected health information, as necessary, to another physician who may be
treating you when we have the necessary permission from you to disclose your
protected health information. Your protected health information may be
provided to a physician to whom you have been referred to ensure that the
physician has the necessary information to diagnose or treat you.
In addition, we may disclose your protected health information from time-to-time
to another physician or health care provider (e.g., a specialist or laboratory)
who, at the request of your physician, becomes involved in your care by
providing assistance with your health care diagnosis or treatment to your
physician.
Payment:
Your protected health information will be used,
as needed, to obtain payment for your health care services. This may
include certain activities that your health insurance plan may undertake before
it approves or pays for the health care services we recommend for you such as;
making a determination of eligibility or coverage for insurance benefits,
reviewing services provided to you for medical necessity, and undertaking
utilization review activities. For example, obtaining approval for
Chiropractic adjustments may require that your relevant protected health
information be disclosed to the health plan to obtain approval for that care.
Healthcare Operations:
We may use or disclose, as-needed, your protected
health information in order to support the business activities of your
physicians practice. These activities include, but are not limited to,
quality assessment activities, employee review activities, training of
Chiropractic students, licensing, marketing and fundraising activities, and
conducting or arranging for other business activities.
For example, we may disclose your protected health information to Chiropractic
school students that see patients at our office. In addition, we may use a
sign-in sheet at the registration desk where you will be asked to sign your name
and indicate your physician. We may also call you by name in the waiting
room when your physician is ready to see you. We may use or disclose your
protected health information, as necessary, to contact you to remind you of your
appointment.
We will share your protected health information with third party "business
associates" that perform various activities (e.g., billing, transcription
services) for the practice. Whenever an arrangement between our office and
a business associate involves the use or disclosure of your protected health
information, we will have a written contract that contains terms that will
protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to
provide you with information about treatment alternatives or other
health-related benefits and services that may be of interest to you. We
may also use and disclose your protected health information for other marketing
activities. For example, your name and address may be used to send you a
newsletter about our practice and the services we offer. We may also send
you information about products or services that we believe may be beneficial to
you. You may contact our Privacy Contact to request that these materials
not be sent to you.
Uses and Disclosures of Protected Health Information Based upon Your Written
Authorization
Other uses and disclosures of your protected health information will be made
only with your written authorization, unless otherwise permitted or required by
law as described below. You may revoke this authorization, at any time, in
writing, except to the extent that your physician or the physicians practice has
taken an action in reliance on the use or disclosure indicated in the
authorization.
With your authorization, we may use or disclose your demographic information and
the dates that you received treatment from your physician, as necessary, in
order to contact you for fundraising activities supported by our office.
If you do not want to receive these materials, please contact our Privacy
Contact and request that these fundraising materials not be sent to you.
Other Permitted and Required Uses and Disclosures That May Be Made With Your
Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following
instances. You have the opportunity to agree or object to the use or
disclosure of all or part of your protected health information. If you are
not present or able to agree or object to the use or disclosure of the protected
health information, then your physician may, using professional judgment,
determine whether the disclosure is in your best interest. In this case,
only the protected health information that is relevant to your health care will
be disclosed.
Others Involved in Your Healthcare:
Unless you object, we may disclose to a member of
your family, a relative, a close friend or any other person you identify, your
protected health information that directly relates to that persons involvement
in your health care. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that
it is in your best interest based on our professional judgment. We may use
or disclose protected health information to notify or assist in notifying a
family member, personal representative or any other person that is responsible
for your care of your location, general condition or death. Finally, we
may use or disclose your protected health information to an authorized public or
private entity to assist in disaster relief efforts and to coordinate uses and
disclosures to family or other individuals involved in your health care.
Emergencies:
We may use or disclose your protected health
information in an emergency treatment situation. If this happens, your
physician shall try to obtain your consent as soon as reasonably practicable
after the delivery of treatment. If your physician or another physician in
the practice is required by law to treat you and the physician has attempted to
obtain your consent but is unable to obtain your consent, he or she may still
use or disclose your protected health information to treat you.
Communication Barriers:
We may use and disclose your protected health
information if your physician or another physician in the practice attempts to
obtain consent from you but is unable to do so due to substantial communication
barriers and the physician determines, using professional judgment, that you
intend to consent to use or disclosure under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your
Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following
situations without your consent or authorization. These situations
include:
Required By Law:
We may use or disclose your protected health
information to the extent that the use or disclosure is required by law.
The use or disclosure will be made in compliance with the law and will be
limited to the relevant requirements of the law. You will be notified, as
required by law, of any such uses or disclosures.
Public Health:
We may disclose your protected health information
for public health activities and purposes to a public health authority that is
permitted by law to collect or receive the information. The disclosure
will be made for the purpose of controlling disease, injury or disability.
We may also disclose your protected health information, if directed by the
public health authority, to a foreign government agency that is collaborating
with the public health authority.
Communicable Diseases:
We may disclose your protected health
information, if authorized by law, to a person who may have been exposed to a
communicable disease or may otherwise be at risk of contracting or spreading the
disease or condition.
Health Oversight:
We may disclose protected health information to a
health oversight agency for activities authorized by law, such as audits,
investigations and inspections. Oversight agencies seeking this
information include government agencies that oversee the health care system,
government benefit programs, other government regulatory programs and civil
rights laws.
Abuse or Neglect:
We may disclose your protected health information
to a public health authority that is authorized by law to receive reports of
child abuse or neglect. In addition, we may disclose your protected health
information if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized to receive
such information. In this case, the disclosure will be made consistent
with the requirements of applicable federal and state laws.
Food and Drug Administration:
We may disclose your protected health information
to a person or company required by the Food and Drug Administration to report
adverse events, product defects or problems, biologic product deviations, track
products; to enable product recalls; to make repairs or replacements, or to
conduct post marketing surveillance, as required.
Legal Proceedings:
We may disclose protected health information in
the course of any judicial or administrative proceeding, in response to an order
of a court or administrative tribunal (to the extent such disclosure is
expressly authorized), in certain conditions in response to a subpoena,
discovery request or other lawful process.
Law Enforcement:
We may also disclose protected health
information, so long as applicable legal requirements are met, for law
enforcement purposes. These law enforcement purposes include (1) legal
processes and otherwise required by law, (2) limited information requests for
identification and location purposes, (3) pertaining to victims of a crime, (4)
suspicion that death has occurred as a result of criminal conduct, (5) in the
event that a crime occurs on the premises of the practice, and (6) medical
emergency (not on the Practice's premises) and it is likely that a crime has
occurred.
Coroners, Funeral Directors and Organ Donation: We may disclose protected health
information to a coroner or medical examiner for identification purposes,
determining 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.
Research:
We may disclose your protected health information
to researchers when their research has been approved by an institutional review
board that has reviewed the research proposal and established protocols to
ensure the privacy of your protected health information.
Criminal Activity:
Consistent with applicable federal and state
laws, we may disclose your protected health information, if we believe 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. We may also
disclose protected health information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Military Activity and National Security:
When the appropriate conditions apply, we may use
or disclose protected health information of individuals who are Armed Forces
personnel (1) for activities deemed necessary by appropriate military command
authorities; (2) for the purpose of a determination by the Department of
Veterans Affairs of your eligibility for benefits, or (3) to foreign military
authority if you are a member of that foreign military services. We may
also disclose your protected health information to authorized federal officials
for conducting national security and intelligence activities, including for the
provision of protective services to the President or others legally authorized.
Workers’ Compensation:
Your protected health information may be
disclosed by us as authorized to comply with workers’ compensation laws and
other similar legally-established programs.
Inmates:
We may use or disclose your protected health
information if you are an inmate of a correctional facility and your physician
created or received your protected health information in the course of providing
care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you
and when required by the Secretary of the Department of Health and Human
Services to investigate or determine our compliance with the requirements of
Section 164.500 et. seq.
2. Your Rights
Following is a statement of your rights with respect to your protected health
information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information.
This means you may inspect and obtain a copy of
protected health information about you 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 use
in, a civil, criminal, or administrative action or proceeding, and protected
health information that is subject to law that prohibits access to protected
health information. Depending on the circumstances, a decision to deny
access may be reviewable. In some circumstances, you may have a right to
have this decision reviewed. Please contact our Privacy Contact if you
have questions about access to your medical record.
You have the right to request a restriction of your protected health
information.
This means you may ask us not to use or disclose
any part of your protected health information for the purposes of treatment,
payment or healthcare operations. You may also request that any part of
your protected health information not be disclosed 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.
Your physician is not required to agree to a restriction that you may
request. If physician believes it is in your best interest to permit use
and disclosure of your protected health information, your protected health
information will not be restricted. If your physician 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. With this in mind, please discuss any restriction you
wish to request with your physician. You may request a restriction by
presenting your request, in writing to the staff member identified as
"Privacy Contact" at the top of this form. A simple sentence,
"Do not use my PHI (Protected Health Information) for education of
Chiropractic Students." or "Do not send any communications to my
home address." Sign and date your request. Ask that the staff
provide you with a photocopy of your request initialed by them. This copy
will serve as your receipt.
You have the right to request to receive confidential communications from us by
alternative means or at an alternative location.
We will accommodate reasonable requests. We
may also 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 request an explanation from you as to the
basis for the request. Please make this request in writing to our Privacy
Contact.
You may have the right to have your physician amend your protected health
information.
This means 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.
Please contact our Privacy Contact to determine if you have questions about
amending your medical record.
You have the right to receive an accounting of certain disclosures we have made,
if any, of your protected health information.
This right applies to disclosures for purposes
other than treatment, payment or healthcare operations as described in this
Notice of Privacy Practices. It excludes disclosures we may have made to
you, for a facility directory, to family members or friends involved in your
care, or for notification purposes. You have the right to receive specific
information regarding these disclosures that occurred after April 14,
2003. You may request a shorter timeframe. The right to receive this
information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request,
even if you have agreed to accept this notice electronically.
3. Complaints
You may complain to us or to the Secretary of Health and Human Services if you
believe your privacy rights have been violated by us. You may file a
complaint with us by notifying our privacy contact of your complaint. We
will not retaliate against you for filing a complaint.
You may contact our Privacy Contact, Rochelle at (313) 881-7677 or
privacy@ahccenter.com for
further information about the complaint process.
This notice was published and becomes effective on April 14, 2003
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