Norton, Klein, Hug, Sabin & Maddens M.D., P.C.
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.
If you have any questions about this notice, please contact Denise Evans-Office Manager for Norton, Klein, Hug,Sabin & Maddens M.D., P.C. at (248) 649-9700 or 3290 W. Big Beaver Ste 420, Troy, MI 48084.
Your medical information is personal. Norton, Klein, Hug, Sabin & Maddens, M.D., P.C. is committed to protecting your medical information. We create a record of the care and services you receive at this office. 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 this office 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 office 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
(3) follow the terms of the Notice that is currently in effect.
How this Office May Use and Disclose Your Medical Information
The following describes the different ways that your medical information may be used or disclosed by this office. 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 you 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, technicians and other office personnel who are involved in providing you medical treatment.
For example, your doctor may be treating you for a heart condition and may need to know if you have other health problems that could complicate your treatment. The doctor may use your medical history to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the most appropriate care for you.
Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy and scheduling diagnostic testing. Family members and other healthcare providers may be part of your medical care outside this office and may require information about you that we have.
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In the course of providing care, your physician will share patient information with other providers who are involved in your care, as appropriate. The data sharing may be through provision of written medical information or through electronic sharing of information.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive at this office 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 you for office operations. These uses and disclosures are necessary to run our office 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 use medical information about all or many of our patients to help us decide what additional services the office should offer, how we can become more efficient, and whether certain new treatments are effective.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at this office.
Treatment Alternatives. We may use and disclose medical information to tell you 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.
Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing(at the address listed at the top of this Notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.
SPECIAL SITUATIONS
We may use or disclose medical information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:
As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
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 connection with audits, investigations, inspections, and licensure renewals, etc. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil rights laws.
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Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose medical information about you in response to a subpoena.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Coroners and Medical Examiners and Funeral Directors. We may release medical information to a coroner, medical examiner, or funeral director This may be necessary, for example, to identify a deceased person or determine the cause of death.
Research. We may use and disclose medical information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address, or other information that reveals who your are, or will be involved in your care at the office.
Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation.
Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release medical information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose medical information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Information Not Personally Identifiable. We may disclose medical information about you in a way that does not personally identify you or reveal who you are.
Family and Friends. We may disclose medical information about you to your family members or friends if we obtain your verbal and/or written agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose medical information to your family or friends if we can infer from the circumstances, based on our professional judgement, that you would not object.
For example, we may assume your agree to our disclosure of your personal medical information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgement, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will only disclose medical information relevant to the person’s involvement in your care. For example, we may inform the person who accompanies you to our office, about the status of your medical condition and provide updates on your progress and prognosis. We may also use our professional judgement and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, prescriptions, laboratory orders, medical reports, etc.
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OTHER USES AND DISCLOSURES OF MEDICAL INFORMATION
We will not use or disclose your medical information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization 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 information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.
If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization (different than the Authorization mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or healthcare operations, we will have to have a special written Authorization that complies with the law governing HIV or substance abuse records.
Your Rights Regarding Your Medical Information:
You have the following rights regarding the medical information this office maintains about you:
Right to Inspect and Copy. You have the right to inspect and copy your medical information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to our Office Manager in order to inspect and/or copy your medical information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend. If you believe the 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 as long as the information is kept by this office.
To request an amendment, complete and submit a Medical Record Amendment/Correction Form to our Office Manager. 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) We did not create, unless the person or entity that created the information is no longer available to make the amendment.
b) Is not part of the medical information that we keep.
c) You would not be permitted to inspect and copy.
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 we made of medical information about you for purposes other than treatment, payment and healthcare operations. To obtain this list, you must submit your request in writing to our Office Manager. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
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Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a specific surgery you had to a family member.
To request restrictions on the use/disclosure of your medical information, you must submit the Request For Restriction On Use/Disclosure Of Medical Information to our Office Manager.
We are Not Required to Agree to Your Request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must complete and submit the Request For Restriction On Use/Disclosure Of Medical Information and/or Confidential communication to our Office Manager. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy.
To obtain a paper copy of this Notice, contact our Office Manager.
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 the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Office Manager at (248)649-9700. All complaints must be submitted in writing.
THIS OFFICE WILL NOT PENALIZE YOU IN ANY WAY FOR FILING A COMPLAINT.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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By signing below I acknowledge that I have received a copy of Norton, Klein, Hug, Sabin & Maddens M.D., P.C.
Notice of Privacy Practices Form.
X________________________________________________ _________________________
Patient Signature Date
______________________________________________________ ______________________
Person signing on behalf of patient (print name) Reason patient cannot sign
__________________________________________________________________________________________
Relationship to patient Address Phone
Documentation of Failure to Obtain Signed Acknowledgement
On _____________________________, 2015, _________________________presented this Acknowledgement
of Receipt of Notice Of Privacy Practices Form to______________________________________(the
“Patient”). The patient refused to provide a signature when requested.
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