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844 East Front Street,
Traverse City
(231) 935-0322 (voice)
(888) 647-0448 (toll-free)
(231) 935-0334 (fax)
Monday - Friday, 8 am - 5 pm
APPOINTMENTS
Traverse City
(231) 935-0322
(888) 647-0448 (Toll-Free)
Frankfort
(231) 352-9621
Kalkaska, Northport, Manistee: (231) 935-0322
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Bay Area Urology
Associates, P.C. Notice of Privacy Practices
As Required by the Privacy Regulations Created as a Result
of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
THIS NOTICE 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 (IIHI). In conducting our business,
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 IIHI. By
federal and state law, we must follow the terms of the notice of privacy
practices that we have in effect at the time.
We realize that these laws are complicated, but we must
provide you with the following important information:
- How we may use and disclose your IIHI
- Your privacy rights in your IIHI
- Our obligations concerning the use and disclosure
of your IIHI
The terms of this notice apply to all records containing
your IIHI that are created or retained by our practice. We reserve the
right to revise or amend this Notice of Privacy Practices. 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. Our practice
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.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE
CONTACT:
Office Manager
844 E. Front St.
P.O. Box 2010
Traverse City, MI 49685-2010
(231) 935-0322
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE
HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may
use and disclose your IIHI.
- Treatment. Our practice may use your IIHI to
treat you. For example, we may ask you to have laboratory tests (such
as blood or urine tests), and we may use the results to help us reach
a diagnosis. We might use your IIHI in order to write a prescription
for you, or we might disclose your IIHI to a pharmacy when we order
a prescription for you. Many of the people who work for our practice
- including, but not limited to, our doctors and nurses - may use
or disclose your IIHI in order to treat you or to assist others in
your treatment. Additionally, we may disclose your IIHI to others
who may assist in your care, such as your spouse, children or parents.
- Payment. Our practice may use and disclose
your IIHI 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 certify that you are eligible for benefits (and for what
range of benefits), and we may provide your insurer with details regarding
your treatment to determine if your insurer will cover, or pay for,
your treatment. We also may use and disclose your IIHI to obtain payment
from third parties that may be responsible for such costs, such as
family members. Also, we may use your IIHI to bill you directly for
services and items.
- Health Care Operations. Our practice may use
and disclose your IIHI to operate our business. As examples of the
ways in which we may use and disclose your information for our operations,
our practice may use your IIHI to evaluate the quality of care you
received from us, or to conduct cost-management and business planning
activities for our practice.
- Appointment Reminders. Our practice may use
and disclose your IIHI to contact you and remind you of an appointment.
- Treatment Options. Our practice may use and
disclose your IIHI to inform you of potential treatment options or
alternatives.
- Health-Related Benefits and Services. Our practice
may use and disclose your IIHI to inform you of health-related benefits
or services that may be of interest to you.
- Release of Information to Family/Friends. Our
practice may release your IIHI to a friend or family member that is
involved in your care, or who assists in taking care of you. For example,
a parent or guardian may ask that a babysitter take their child to
the pediatrician's office for treatment of a cold. In this example,
the babysitter may have access to this child's medical information.
- Disclosures Required By Law. Our practice will
use and disclose your IIHI when we are required to do so by federal,
state or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL
CIRCUMSTANCES
The following categories describe unique
scenarios in which we may use or disclose your identifiable health information:
- Public Health Risks. Our practice may disclose
your IIHI to public health authorities that are authorized by law
to collect information for the purpose of:
- maintaining vital records, such as births and deaths
- reporting child abuse or neglect
- preventing or controlling disease, injury or disability
- notifying a person regarding potential exposure
to a communicable disease
- notifying a person regarding a potential risk for
spreading or contracting a disease or condition
- 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 agency(ies) and
authority(ies) regarding the potential abuse or neglect of an adult
patient (including domestic violence); however, we will only disclose
this information if the patient agrees or we are required or authorized
by law to disclose this information
- notifying your employer under limited circumstances
related primarily to workplace injury or illness or medical surveillance.
- Health Oversight Activities. Our practice may
disclose your IIHI to a health oversight agency for activities authorized
by law. Oversight activities can include, for example, 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.
- Lawsuits and Similar Proceedings. Our practice
may use and disclose your IIHI in response to a court or administrative
order, if you are involved in a lawsuit or similar proceeding. We
also may disclose your IIHI 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.
- Law Enforcement. We may release IIHI 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
- Regarding criminal conduct at our offices
- 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)
- Deceased Patients. Our practice may release
IIHI 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.
- Organ and Tissue Donation. Our practice may
release your IIHI to organizations that handle organ, eye or tissue
procurement or transplantation, including organ donation banks, as
necessary to facilitate organ or tissue donation and transplantation
if you are an organ donor.
- Research. Our practice may use and disclose
your IIHI for research purposes in certain limited circumstances.
We will obtain your written authorization to use your IIHI for research
purposes except when: (a) our use or disclosure was approved by an
Institutional Review Board or a Privacy Board; (b) we obtain the oral
or written agreement of a researcher that (i) the information being
sought is necessary for the research study; (ii) the use or disclosure
of your IIHI is being used only for the research and (iii) the researcher
will not remove any of your IIHI from our practice; or (c) the IIHI
sought by the researcher only relates to decedents and the researcher
agrees either orally or in writing that the use or disclosure is necessary
for the research and, if we request it,
to provide us with proof of death prior to access to the IIHI of the
decedents.
- Serious Threats to Health or Safety. Our practice
may use and disclose your IIHI 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.
- Military. Our practice may disclose your IIHI
if you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate authorities.
- National Security. Our practice may disclose
your IIHI to federal officials for intelligence and national security
activities authorized by law. We also may disclose your IIHI to federal
officials in order to protect the President, other officials or foreign
heads of state, or to conduct investigations.
- Inmates. Our practice may disclose your IIHI
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.
- Workers' Compensation. Our practice may release
your IIHI for workers' compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI
that we maintain about you:
- 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 Office Manager 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.
- Requesting Restrictions. You have the right
to request a restriction in our use or disclosure of your IIHI for
treatment, payment or health care operations. Additionally, you have
the right to request that we restrict our disclosure of your IIHI
to only certain individuals involved in your care or the payment for
your care, such as family members and friends. We are not required
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 IIHI, you must make
your request in writing to Office Manager. Your request must describe
in a clear and concise fashion:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice's use, disclosure
or both; and
(c) to whom you want the limits to apply.
- Inspection and Copies. You have the right to
inspect and obtain a copy of the IIHI that may be used to make decisions
about you, including patient medical records and billing records,
but not including psychotherapy notes. You must submit your request
in writing to Office Manager in order to inspect and/or obtain a copy
of your IIHI. Our practice may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. Our practice
may deny your request to inspect and/or copy in certain limited circumstances;
however, you may request a review of our denial. Another licensed
health care professional chosen by us will conduct reviews.
- 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
or for our practice. To request an amendment, your request must be
made in writing and submitted to Office Manager. You must provide
us with a reason that supports your request for amendment. Our practice
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 IIHI kept by or for
the practice; (c) not part of the IIHI which you would be permitted
to inspect and copy; or (d) not created by our practice, unless the
individual or entity that created the information is not available
to amend the information.
- Accounting of Disclosures. All of our patients
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 IIHI for non-treatment or
operations purposes. Use of your IIHI 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. In order to obtain
an accounting of disclosures, you must submit your request in writing
to Office Manager. 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. The first list you request within a 12-month period is free
of charge, but our practice may charge you for additional lists within
the same 12-month period. Our practice will notify you of the costs
involved with additional requests, and you may withdraw your request
before you incur any costs.
- 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 Office Manager.
- 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 Office Manager.
All complaints must be submitted in writing. You will not be penalized
for filing a complaint.
- 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 IIHI may be revoked at any time in
writing. After you revoke your authorization, we will no longer use
or disclose your IIHI for the reasons described in the authorization.
Please note, we are required to retain records of your care.
Again, if you have any questions regarding this notice
or our health information privacy policies, please contact Office
Manager.
(231) 935-0322
(888) 647-0448 (Toll-Free)
associates@bayareaurology.com
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