Effective: APRIL 1ST 2003
Great Lakes Surgical Center Notice Of Privacy Practices
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.
Your medical information is personal. We are committed to
protecting your medical information. We create a record of
the care and services you receive at any of our offices. We
need this record to provide you with quality care and to comply
with certain legal requirements. This NOTICE applies to all
of the records of your care generated by any of our offices
whether made by your personal physician or one of the office’s
employees.
This NOTICE will tell you about the ways in which we may
use and disclose your medical information. This NOTICE will
also describe your rights and certain obligations we have
regarding the use and disclosure of your medical information.
This practice is required by law to:
1) Make sure that medical information that
identifies you is kept private;
2) Give you this NOTICE of our legal duties
and privacy practices with respect to medical information
about you; and
3) Follow the terms of the NOTICE that is
currently in effect.
How this Practice May Use and Disclose Your Medical Information
The following describes the different ways that your medical
information may be used or disclosed by this practice. For
clarification we have included some examples. Not every possible
use or disclosure is specifically mentioned. However, all
of the ways we are permitted to use and disclose your medical
information will fit within one of these general categories:
For Treatment. We will use medical information
about you to provide you with medical treatment and services.
We may disclose medical information about you to doctors,
nurses, Pas, technicians and other office personnel who are
involved in providing you medical treatment.
For Payment. We may use and disclose medical
information about you so that the treatment and services you
receive at this practice may be billed to and payment may
be collected from you, an insurance company or a third party.
For example, we may need to give your health plan information
about treatment you received here so your health plan will
pay us or reimburse you for the treatment. We may also tell
your health plan about a treatment you are going to receive
to obtain prior approval or to determine whether your plan
will cover the treatment.
For Health Care Operations. We may use and
disclose medical information about your for office operations.
These uses and disclosures are necessary to run our offices
and make sure that all of our patients receive quality care.
For example, we may use medical information to review our
treatment and services and to evaluate the performance of
our staff in caring for you. We may also combine medical information
about many of our patients to decide what additional services
the practice should offer, what services are not needed, and
whether certain new treatments are effective. We may also
disclose information to doctors, PAs, nurses, technicians
and other office personnel for review and learning purposes.
We may remove information that identifies you from this set
of medical information so others may use it to study healthcare
and health care delivery without learning the identity of
the specific patients.
Appointment Reminders. We may use and disclose
medical information to contact your as a reminder that your
have an appointment for treatment or medical care at one of
our offices.
Treatment Alternatives. We may use and disclose
medical information to tell your about or recommend possible
treatment options or alternatives that may be of interest
to you.
Health-Related Benefits and Services. We
may use and disclose medical information to tell you about
health-related benefits or services that may be of interest
to you.
Research. Under certain circumstances, we
may use and disclose medical information about you for research
purposes. For example, a research project may involve comparing
the health and recovery of all patients who received one mediation
to those who received another for the same condition.
As Required By Law. We will disclose medical
information about you when required to do so by federal, state
or local law. For example, disclosure may be required by Workers’
Compensation statutes and various public health statutes in
connection with required reporting of certain diseases, child
abuse and neglect, domestic violence, adverse drug reactions,
etc.
To Avert a Serious Threat to Health or Safety. We
may use and disclose medical information about you when necessary
to prevent a serious threat to your health and safety or the
health and safety of the public or another person. Any disclosure,
however, would only be to someone able to help prevent the
threat.
Health Oversight Activities. We may disclose
medical information to a governmental or other oversight agency
for activities authorized by law. For example, disclosures
of your medical information may be made in connections with
audits, investigations, inspections, and licensure renewals,
etc.
Lawsuits and Disputes. If you are involved
n a lawsuit or a dispute, we may use your medical information
to defend the practice or to respond to a court order.
Law Enforcement. We may release medical
information about you if required by law when asked to do
so by a law enforcement official.
Coroners and Medical Examiners. We may release
medical information to a coroner or medical examiner to identify
a deceased person or determine the cause of death.
Your Rights Regarding Your
Medical Information:
You have the following rights regarding the medical information
this practice maintains about you:
Right to Inspect and Copy. You have the
right to inspect and copy your medical information with the
exception of any psychotherapy notes.
To inspect and copy your medical information, you must submit
your request in writing to 26051 Lahser Road, Southfield,
MI 48034. If you request a copy of the information we may
charge a fee for the costs of copying, mailing or other supplies
associated with your request.
We may deny your request to inspect and copy in certain
very limited circumstances. If you are denied access of your
medical information, you may request that the denial be reviewed.
For information regarding such a review contact the Practice
Administrator.
Right to Amend. If you feel that medical
information we have about you is incorrect or incomplete,
you may ask us to amend the information, you have the right
to request an amendment for as long as the information is
kept by this practice.
To request an amendment, your request must be made in writing
and submitted to the Practice Administrator. In addition,
you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in
writing or does not include a reason to support the request.
In addition, we may deny your request if you ask us to amend
information that:
a. Was not created by us;
b. Is not part of the medical information
kept by this office;
c. Is not part of the information which your
would be permitted to inspect and copy; or
d. Is accurate and complete.
Right to an Accounting of Disclosures. You
have the right to request an “accounting of disclosures.”
This is a list of the disclosures this office has made of
your medical information.
To request this accounting of disclosures, you must submit
your request in writing to the Practice Administrator. Your
request must state a time period which may not be longer than
six ears and may not include dates before February 26, 2003.
Right to Request Restrictions. You have
the right to request a restriction or limitation on the use
or disclosure we make of your medical information.
We are not required to agree to our request for a restriction.
If we do agree, we will comply with your request unless the
information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing
to the Practice Administrator.
Right to Request Confidential Communications.
You have the right to request that we communicate with you
only in a certain manner. For example, you can ask that we
only contact you are work or by mail.
To request confidential communications, you must make your
request in writing to the Practice Administrator. We will
accommodate all reasonable requests.
Right to a Paper Copy of This Notice. You
have the right to a paper copy of this NOTICE. Even if you
have agreed to receive this NOTICE electronically, you are
still entitled to a paper copy of this NOTICE.
You may obtain a copy of this on our web site www.greatlakesasc.com.
To obtain a paper copy of the NOTICE, contact personnel at
248-223-9925.
Revisions to This NOTICE
We reserve the right to revise this NOTICE. Any revised NOTICE
Will be effective for medical information we already have
about you as well as any information we receive in the future.
We will post a copy of any revised NOTICE in this office as
well as on our web site. Any revised NOTICE will contain the
first page, in the top right-hand corner, the effective date.
In addition, each time you visit our offices you may request
a copy of the current NOTICE in effect.
Complaints
If you believe your privacy rights have been violated, you
may file a complaint with this office or with the Secretary
of Health and Human Services. To file a complaint with this
office, contact at 248-223-9925. All complaints must be submitted
in writing.
THIS OFFICE WILL NOT PENALIZE YOU IN ANY WAY FOR
FILING A COMPLAINT.
Other Uses of Medical Information
Other uses and disclosures of your medical information not
covered by this Notice of Privacy Practices will be made only
with your written authorization. If you provide us with such
an authorization in writing to use or disclose medical information
about you, you may revoke that authorization, in writing,
at any time. If you revoke your authorization, we will no
longer use or disclose medical information about you for the
reasons covered by your written authorization.
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