This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.
Protected health information (PHI), about you, is maintained as a written &/or electronic record of your contacts or visits for healthcare services with Family Medicine of Michigan. Specifically, “PHI” is information about you, including demographic information (i.e. name, address, phone, etc.) that may identify you and relates to your past, present or future physical or mental health condition and related health care services.
Family Medicine of Michigan is required to follow specific rules on maintaining the confidentiality of your PHI, using your information and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.
If you have any questions about this Notice, please contact our Privacy Manager.
YOUR RIGHTS UNDER THE PRIVACY RULE
Following is a statement of your rights, under the Privacy Rule, in reference to your protected health information (PHI). Please feel free to discuss any questions with our staff.
You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices – We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous place within our office and website (www.familymedicineofmichigan.com).
You have the right to authorize other use and disclosure – This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or FMOM has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to designate a personal representative – This means you may designate a person with the delegated authority to consent to or authorize the use or disclosure of protected health information.
You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about medical matters using an alternative method (i.e.portal, telephone, etc.) and to a destination (i.e. cell phone number, alternative address, etc.) designated by you. You must inform us in writing how you wish to be contacted (using a form provided by FMOM), if other than the address &/or phone number that we have on file. We will follow all reasonable requests.
You have the right to inspect and copy your PHI – This means you may inspect and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state or federal guidelines.
You have the right to request a restriction of your PHI – This means you may ask us, in writing, not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you or someone on your behalf, has paid for, in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.
You may have the right to request an amendment to your PHI – This means you may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request for an amendment.
You have the right to request disclosure accountability – This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of FMOM.
You have the right to receive a privacy breach notice – You have the right to receive written notification if FMOM discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.
HOW WE MAY USE OR DISCLOSE PROTECTED HEALTH INFORMATION
Following are examples of uses and disclosures of your PHI information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by FMOM.
Treatment – We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other healthcare providers who may be involved in your care and treatment.
Special Notices – We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact your by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each notice will include instructions of opting out.
Payment – Your PHI 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.
Healthcare Operations – We may use or disclose, as needed, your PHI in order to support the business activities of FMOM. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.
Health Information Organizations – Family Medicine of Michigan may elect to use a health information organization or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment or healthcare operations.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES
We may also use and disclose your protected health information (PHI) in the following instances as outlined below.
To Others Involved in Your Healthcare – We may disclose to a member of your family, a relative, a close friend or any other person, that you identify by completing a signed release of information, any PHI that you authorize. 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 PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care, general condition, or death. In any case, only the PHI that is necessary will be disclosed. Under Michigan law, however, we would only disclose health information related to a minor’s treatment for venereal diseases and HIV testing, substance abuse, behavioral health and prenatal/pregnancy treatment for those reasons required by law.
As Required By Law – We may use or disclose your PHI to the extent that the use or disclosure is required by law.
For Public Health – We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.
For Communicable Diseases – We may disclose your PHI, 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.
For Health Oversight – We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations and inspections.
In Cases of Abuse or Neglect – We may disclose your PHI to a public health authority that is authorized by law to receive reports or child abuse or neglect. In addition, we may disclose your PHI 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.
To the Food and Drug Administration – We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, to monitor product defects or problems, to report biologic product deviations, to track products, to enable product recalls, to make repairs or replacements or to conduct post-marketing surveillance, as required.
To Coroners, Funeral Directors, and Organ Donations – We may disclose PHI 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 PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
To Law Enforcement – We may also disclose PHI, as long as applicable legal requirements are met, for law enforcement purposes.
For Legal Proceedings – We may disclose PHI 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.
For Research – We may disclose your PHI to researchers when an institutional review board has reviewed and approved the research proposal and established protocols to ensure the privacy of PHI.
In Cases of Criminal Activity – Consistent with applicable federal and state laws, we may disclose your PHI, 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 PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
For Military Activity and National Security – When the appropriate conditions apply, we may useor disclose PHI 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 service.
For Workers’ Compensation – Your PHI may be disclosed by us, as authorized, to comply with workers’ compensation laws and other similar legally-established programs.
When an Inmate – We may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.
Required Uses and Disclosures – Under the law, we must make disclosures about 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 the Privacy Rule.
You have the right to address complaints to us or to the Secretary of the Department 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 Manager of your complaint at:
Revised Date 07/8/2015