OF PRIVACY PRACTICES
April 14th, 2003
THIS NOTICE DESCRIBES
HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION.
REVIEW IT CAREFULLY.
applies to the privacy practices of this agency that may share your Protected
Health Information as needed for treatment, payment, and health care
notice will tell you how we may use and disclose protected health information
about you. Protected health information
means any health information about you that identifies you or for which there
is a reasonable basis to believe the information can be used to identify
you. In this notice we call all of that
protected health information “medical information.”
notice will also tell you about your rights and our duties with respect to
medical information about you. In
addition, it will tell you how to file a complaint if you believe we have
violated your privacy rights.
We May Use and Disclose Medical Information About You
may use medical information about you to provide, coordinate, or manage your
health care and related services by both us and other health care
providers. We may disclose medical
information about you to other health care providers (doctors, nurses,
hospitals, dentists, and other caregivers) who become involved in your
care. We may consult with other health
care providers concerning you and as part of the consultation, share your
medical information with them. Similarly,
we may refer you to another health care provider, and as part of the referral,
share medical information about you with that provider. For example, we may conclude you need to
receive services from a physician with a particular specialty. When we refer you to that physician, we will
also contact that physician’s office and provide medical information about you
to them, so that they have the information they need to provide services for
For Health Care Operations.
may use and disclose medical information about you for our own health care
operations. These are necessary for us
to operate and to maintain quality health care for our consumers. For example:
o To review the services we provide, and
the performance of our employees in caring for you.
o To train our staff or volunteers.
o In conducting quality assessment and
improvement activities, including peer review, credentialing of providers, and
o In preventing, detecting, and
investigating fraud and abuse.
o In coordinating case and disease
may use and disclose medical information about you so we can be paid for the
services we provide to you. We may need
to provide a third-party payer, our funding source, or a government program,
such as Medicare or Medicaid, with information about your medical condition, as
well as the health care you need to receive.
How We Will Contact You.
you tell us otherwise in writing, we may contact you by either telephone or
mail, at either your home or workplace.
At either location, we may leave messages for you on the answering
machine or voicemail. If you want to
request that we communicate to you in a certain way or at a certain location,
please see “Right to Receive Confidential Communications” as part of this
may use and disclose medical information about you to communicate with you
about a product or service, to encourage you to purchase the product or
service. This may be:
o To describe a health-related product
or service that is provided by us.
o For your treatment.
o For case management or
care-coordination for you.
o To direct or recommend alternative
treatments, therapies, or health care providers.
may communicate to you about products and services in a face-to-face communication
by us to you. We may also communicate
about products or services in the form of a promotional gift of nominal value.
other use and disclosure of medical information about you, by us, to make a
communication about a product or service, to encourage the purchase or use of a
product or service, will be done only with your written authorization.
may use and disclose medical information about you to contact you to raise
funds for our company. We may disclose
medical information to a business associate or a foundation related to our
company, so that business associate or foundation may contact you to raise
money for the benefit of our company. We
will only release demographic information, such as your name and address, and
the dates you received treatment or services from us. If you do not want our company or its
foundation to contact you for fundraising, you must notify the program manager
Individuals Involved in Your Care.
may disclose to a family member, other relative, a close personal friend, or
any other person identified by you, medical information about you that is
directly relevant to that person’s involvement with your care, or payment
related to your care. We also may use or
disclose medical information about you to notify, or assist in notifying, those
persons of your location, general condition, or death. If there is a family member, other relative,
or close personal friend to whom you do not want us to disclose medical
information about you, please notify the program manager, or tell our staff
member who is providing care to you.
may use or disclose medical information about you to a public or private entity
authorized by law or by its charter to assist in disaster relief efforts. This will be done to coordinate with those
entities in notifying a family member, other relative, close personal friend,
or other person identified by you, of your location, general condition, or
Public Health Activities.
may disclose medical information about you for public health activities and
purposes. This includes reporting
medical information to a public health authority that is authorized by law to
collect or receive the information for purposes of providing or controlling
disease, or one that is authorized to receive reports of abuse and neglect.
also includes reporting for purposes of activities relating to the quality,
safety, or effectiveness of a United States Food and Drug Administration
regulated product or activity.
Victims of Abuse, Neglect, or Domestic
may disclose medical information about you to government authorities, including
social services or protective service agencies, if we reasonably believe you
are a victim of abuse, neglect, or domestic violence. This will occur to the extent that the
disclosure is: (a) required by law, (b) agreed to by you, or (c) authorized by
law and we believe the disclosure is necessary to prevent serious harm to you
or to other potential victims, or if you are incapacitated and certain other
conditions are met, a law enforcement or other public official represents that
immediate enforcement activity depends on the disclosure.
Health Oversight Activities.
may disclose medical information about you to a health oversight agency for
activities authorized by law- including audits, investigations, inspections,
licensure, or disciplinary actions.
These and similar types of activities are necessary for appropriate
oversight of the health care system, government benefit programs, and entities
subject to various government regulations.
Judicial and Administrative
may disclose medical information about you in the course of any judicial or
administrative proceeding in response to an order of the court or administrative
tribunal. We may also disclose medical
information about you in response to a subpoena, discovery request, or other
legal process, but only if efforts have been made to tell you about the request
or to obtain an order protecting the information to be disclosed.
Disclosures for Law Enforcement
may disclose medical information about you to a law enforcement official for
law enforcement purposes:
o As required by law.
o In response to a court, grand jury, administrative
order, warrant, or subpoena.
o To identify or locate a material
witness or missing person.
o About an actual or suspected victim of
a crime, and that person agrees to the disclosure. If we are unable to obtain that person’s
agreement, in limited circumstances, the information may still be disclosed.
o To alert law enforcement officials to
a death if we suspect the death may have resulted from criminal conduct.
o About crimes that occur at our
o About medical emergencies, if the
disclosure is necessary to alert law enforcement about the commission and
nature of a crime, the location of victims, or the perpetrator of such crime.
Coroners and Medical Examiners.
may disclose medical information about you to a coroner or medical examiner for
purposes such as identification and determining cause of death.
may disclose medical information about you to funeral directors as necessary
for them to carry out their duties.
Organ, Eye, or Tissue Donation.
facilitate organ, eye, or tissue donation and transplantation, we may disclose
medical information about you to organ procurement organizations, or other
entities engaged in the procurement, banking, or transplantation of organs,
eyes, or tissue.,
may use or disclose medical information about you for research, provided that
certain conditions are met.
To Avert Serious Threat to Health or
may use or disclose protected health information about you if we believe that
the use or disclosure is necessary to prevent or lessen a serious or imminent threat
to the health or safety of a person or the public. We also may release information about you if
we believe the disclosure is necessary for law enforcement authorities to
identify or apprehend an individual who admitted participation in a violent crime,
who is an escapee from a correctional institution, or from lawful custody.
Inmates, Persons in Custody.
may disclose medical information about you to a correctional institution or law
enforcement official having custody of you.
The disclosure will be made if the disclosure is necessary: (a) to
provide health care to you, (b) for the health and safety of others, or (c) the
safety, security, and good order of the correctional institution.
Specialized Government Functions.
may use or disclose medical information about you if you are a member of the
Armed Forces or foreign military personal, if appropriate notice has been filed
in the Federal Register.
may disclose medical information about you to authorized federal officials for
the conduct of lawful intelligence, counter-intelligence, and other national
security activities, or for federal protective services and investigations, to
the extent authorized by law.
may disclose medical information about you to the extent necessary to comply
with workers’ compensation and similar laws that provide benefits for
work-related injuries or illness, without regard to fault.
Other Uses and Disclosures.
uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any
time by notifying the program manager in writing of your desire to revoke
it. However, if you revoke such an
authorization, it will not have any affect on actions taken by us in reliance
Rights with Respect to Medical Information About You
You have the following rights with
respect to medical information that we maintain about you.
Right to Request Restrictions.
have the right to request that we restrict the uses or disclosures of medical
information about you to carry out treatment, payment, or health care
operations. You also have the right to
request that we restrict the uses or disclosures we make to: (a) a family
member, other relative, a close personal friend, or any other person identified
by you, or (b) to public or private entities for disaster relief efforts.
request a restriction, you may do so at any time. If you request a restriction, you should do
so to the program manager, and tell us: (a) what information you want to limit,
(b) whether you want to limit use or disclosure, or both, and (c) to whom you
want the limits to apply (for example, disclosures to your parent).
We are not required to
agree to any requested restriction. However,
if we do agree, we will follow that restriction unless the information is
needed to provide emergency treatment.
Right to Receive Confidential
have the right to request that we communicate medical information about you to
you in a certain way, or at a certain location.
For example, you can ask that we only contact you by mail or at
work. We will not require you to tell us
why you are asking for confidential communication.
you want to request confidential communication, you must do so in writing, to
the program manager. We may condition
our acceptance of this accommodation upon obtaining appropriate information
regarding payment, and upon receiving an alternative method to contact you.
Right to Access Protected Health
have a right to request access to inspect or obtain a copy of your medical
information that is contained in a designated record set. You must make such request in writing to the
program manager at your facility. If we
deny your request, we will provide a basis for the denial in writing. If your request is denied, under certain
circumstances, you have the right to have your request reviewed by a licensed
health care professional, designated by us.
We may charge you for the reasonable copy and postage costs if you
request a copy of the records.
Right to Amend.
have the right to ask us to amend medical information about you. You have this right for so long as we
maintain the medical information. If we
deny your request, we will provide you a written explanation. If you disagree, you may have a statement of
your disagreement placed in our records.
If we accept your request to amend the information, we will make
reasonable efforts to inform others, including individuals you name, of the
request an amendment, you must submit your request in writing to the program
manager. Your request must state the
amendment desired and provide a reason in support of that amendment.
Right to an Accounting of Disclosures.
have the right to receive an accounting of disclosures of medical information
about you. The accounting may be for up
to six (6) years prior to the date on which you request the accounting, but not
before April 14, 2003.
Our Rights, Questions,
We are required to maintain the
privacy of protected health information and to provide individuals with notice
of our legal duties and privacy practices, with respect to protected health
information. We are required to abide by
the terms of this Notice of Privacy Practices currently in effect. 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.
Availability of Notice of Privacy
copy of our current Notice of Privacy Practices will be posted on the “consumer
information” bulletin board. A copy of
the current notice will also be posted on our web site. At any time, you may obtain a copy of the
current Notice of Privacy Practices by contacting the program manager.
may complain to us and to the United States Secretary of Health and Human
Services if you believe your privacy rights have been violated by us.
Office for Civil
Department of Health and Human Services, 200 Independence Avenue, SW, Washington
file a complaint with us, write or call: Privacy
Officer at 2950 W. Square Lake
Road, Suite 209, Troy, MI 48098. Telephone: 248-641-7200.
complaints should be submitted in writing.
You will not be retaliated against for filing a complaint.
Questions and Information.
you have any questions or want more information concerning this Notice of
Privacy Practices, you can write or call:
Privacy Officer at 2950
W. Square Lake Rd., Suite 209, Troy, MI 48098