This, notice, as required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act (HIPAA), describes how health information about you, as a patient of this practice, may be used and disclosed and how you can get access to your individually identifiable health information. Please review this notice carefully.

A. Our commitment to your privacy:
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In the normal conduct of a medical practice, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. This document is to inform you of how we may use and disclose your PHI, your privacy rights, and our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices at any time. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. We will post a copy of our current Notice in our offices in a visible location at all times, a copy will be posted on our web site, and you may request a copy of our most current Notice at any time.

B. If you have questions about this Notice, please contact Carol Chusid, R.N. Phone (231) 773-3258

C. We may use and disclose your PHI in the following ways:
The following categories describe the different ways in which we may use and disclose your PHI in the normal operation of our practice.
1. Treatment. Our practice may use your PHI to treat you and review treatment options. Many of the people who work for our practice may use or disclose your PHI in order to treat you or to assist others in your treatment. We may disclose your PHI to others who assist in your care, such as your spouse, children or parents. We may disclose your PHI to other health care providers for purposes related to your care. This may include other physicians involved in your care, such as physicians who may have referred you to us for treatment, other physicians we have referred you to, or any other physicians involved in your care. It may include other professionals such as home nursing agencies, physical therapists, nurse educators, and dieticians. We might use your PHI in order to write a prescription, or we might disclose your PHI to a pharmacy when we order a prescription for you. Information may be disclosed to students involved in your care as part of their education. If you are receiving prescriptions for controlled substances, such as narcotic pain medications, we may exchange information with other health care providers and pharmacies to investigate potential misuse of such medications, such as receiving controlled substances from more than one source.
2. Payment. Our practice 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 determine if you are eligible for benefits, and we may provide your insurer with details regarding your treatment to determine if your insurer will cover your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. 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. Your PHI may be disclosed to collection agencies should their services be required to collect on delinquent accounts.
3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, we may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.
4. Appointment reminders. Our practice may use your PHI to contact you and remind you of an appointment.
5. Release of information to family and friends involved in your care. Our practice may release your PHI to family members, friends, and other caregivers who are involved in your care, or who assist in taking care of you.
6. Disclosures required by law. Our practice will use and disclose your PHI when we are required to by federal, state or local law.

D. Use and disclosure of your PHI in certain special circumstances:
The following categories describe special situations in which we may use or disclose your identifiable health information:

1. Public health concerns. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
• Maintaining vital records, such as births and deaths
• Preventing or controlling disease, injury or disability,
• Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease,
• Reporting reactions to drugs or problems with products or devices,
• Notifying individuals if a product or device they may be using has been recalled,
• Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of a patient, including domestic violence, as authorized by law.
2. Health oversight activities. Our practice may disclose 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 laws and the health care system in general.
3. Lawsuits and similar proceedings. Our practice 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.4. Law enforcement. We may release PHI if asked to do so by a law enforcement official:
• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement,
• Concerning a death we believe has resulted from criminal conduct,
• In the event that a crime occurs on the premises of our practice,
• In response to a warrant, summons, court order, subpoena or similar legal process,
• To identify/locate a suspect, material witness, fugitive or missing person,
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator). 5. Serious threats to health or safety. Our practice 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. Our practice 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. Our practice may disclose your PHI to federal officials for intelligence and national security activities required by law.
8. Inmates. Our practice 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/or (c) to protect your health and safety or the health and safety of other individuals.
9. Workers’ compensation. Our practice may release your PHI as authorized to comply with workers’ compensation laws and other similar legally-established programs.

E. Your rights regarding your PHI:
You have the following rights regarding the protected health information (PHI) that we maintain about you:

1. Confidential communications. You have the right to request that our practice 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. In order to request a type of confidential communication, you must make a written request to our office specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI beyond those otherwise required under HIPAA privacy rules. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required by law to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to our office. Your request must describe in a clear and concise fashion:
• The information you wish restricted,
• Whether you are requesting to limit our practice’s use, disclosure or both,
• To whom you want the limits to apply.
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. Under federal law you do not have the right to 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 not required to be accessible under the HIPAA Privacy Rules or other applicable laws. You must submit your request in writing to our office in order to obtain a copy of your PHI. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect or copy PHI in certain limited circumstances. You may request a review of our denial. Another health care professional chosen by us will conduct the review.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by our practice. To request an amendment, your request must be made in writing and submitted to our office. You must provide us with a reason that supports your request for amendment. We may legally deny a request that is not in writing or does not include a reason that supports the request, involves information that was not created by us (unless the person that created the information is no longer available to make the amendment), is not part of the medical information maintained by our practice, is not part of the information which you would be permitted to inspect and copy, or pertains to information that is accurate and complete.
5. Accounting of disclosures. You have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment, or operations. Use of your PHI as part of routine patient care in our practice, including communication with healthcare professionals, family members or friends involved in your care, and use of information for billing purposes, is not required to be documented In order to obtain an accounting of disclosures, you must submit your request in writing to our office. All requests for an accounting of disclosures must state a time period, which may not be longer than six years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a twelve month period is free of charge, but we may charge you for additional lists within the same twelve month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Carol Chusid, R.N. Phone (231) 773-3258
7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Carol Chusid, R.N. Phone (231) 773-3258. All complaints must be submitted in writing. No retaliatory action will be taken against you for making a complaint.
8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

If you have any questions regarding this notice or our health information privacy policies, please contact Carol Chusid, R.N. Phone (231) 773-3258
This notice is effective on April 14, 2003.