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.

This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your protected health information (PHI). It also describes your rights to access and control your PHI under certain conditions. Your PHI means any written and oral health information, including demographic data that can be used to identify you, that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

I. Uses and Disclosures of PHI

We will use your PHI for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your PHI will be used or disclosed only for these purposes unless we have obtained your authorization, or if it is otherwise permitted by HIPAA Privacy Regulations or State law. Disclosures of your PHI for the purposes described in this Notice may be made in writing, orally, or by facsimile.

A. Treatment. We will use and disclose your PHI to provide, coordinate, or manage your health care. This includes the coordination or management of your health care with a third party for treatment purposes. For example, we may disclose your PHI to a pharmacy to fulfi ll a prescription, to a laboratory to order a blood test, or to a home health agency that is providing care in your home. We may also disclose PHI to other physicians who may be treating you or consulting with your physician with respect to your care.

B. Payment. Your PHI will be used to obtain payment for the services that we provide. This may include communications to your health insurer to get approval for the treatment that we recommend. We may also disclose PHI to your insurance company to determine whether you are eligible for benefi ts or whether a particular service is covered under your health plan. In order to get payment for our services, we may also need to disclose your PHI to your insurance company to demonstrate medical necessity of the services or for utilization review. We may also disclose patient information to another provider involved in your care for the other provider’s payment activities.

C. Operations. We may use or disclose your PHI, for our own health care operations or to provide quality care to all patients. These health care operations include such activities as:
· Quality assessment and improvement activities.
· Employee review activities.
· Training programs including those in which students, trainees, or practitioners in health care learn under our supervision.
· Accreditation, certifi cation, licensing or credentialing activities.
· Review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs.
· Business management and general administrative activities.
In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

D. Other Uses and Disclosures. As part of treatment, payment and healthcare operations, we may also use or disclose your PHI for the following purposes:
· To remind you of an appointment.
· To inform you of potential treatment alternatives or options.
· To inform you of health-related benefi ts or services that may be of interest to you.

II. Uses and Disclosures Beyond Treatment, Payment, and Health Care Operations that are Permitted Without Authorization or Opportunity to Object

Federal privacy rules allow us to use or disclose your PHI without your permission or authorization for a number of reasons including the following:

A. When Legally Required. We will disclose your PHI when we are required to do so by any Federal, State or local law.

B. When There Are Risks to Public Health. We may disclose your PHI for the following public activities and purposes when permitted or required by law:
· To prevent, control, or report disease, injury or disability.
· To conduct public health surveillance, investigations and interventions.
· To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
· To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
· To report information to your employer as legally permitted or required.

C. To Report Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that you are the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifi cally required or authorized by law or when your agree to the disclosure.

D. To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefi ts.

E. In Connection With Judicial And Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena in some circumstances.

F. For Law Enforcement Purposes. We may disclose your PHI to a law enforcement offi cial for the following purposes:
· As required by law for reporting of certain types of wounds or other physical injuries.
· Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.
· For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
· Under certain limited circumstances, when you are the victim of a crime.
· If your physician has a suspicion that your death was the result of criminal conduct.
· In an emergency in order to report a crime.

G. To Coroners, Funeral Directors, and for Organ Donation. We may disclose PHI to a coroner or medical examiner for identifi cation purposes, to determine 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 in order to permit the funeral director to carry out their duties.

H. For Research Purposes. We may use or disclose your PHI for research when the research has been approved by an institutional review or privacy board that has reviewed the research proposal and research protocols to address the privacy of your PHI.

I. In the Event of A Serious Threat To Health Or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. For example, if you threaten suicide or harm to another individual.

J. For Specifi ed Government Functions. In certain circumstances, Federal regulations authorize the provider to use or disclose your PHI to facilitate specifi ed government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.

K. For Worker’s Compensation. The provider may release your health information to comply with worker’s compensation laws or similar programs.

III. Use and Disclosure Permitted Without Authorization but With Opportunity to Object

We may disclose your PHI to a family member or a close personal friend if it is directly relevant to that person’s involvement in your care or payment related to your care. We can also disclose your information to family members or others involved in your care in connection with their concerns related to your location, condition or death.
You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interest for us to make disclosure of information that is directly relevant to the person’s involvement with your care, we may disclose your PHI as described.

IV. Uses and Disclosures Which You Authorize

Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

V. Your Rights

You have the following rights regarding your health information:
A. The right to inspect and copy your PHI. You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records that your physician uses for making decisions about you.
Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to a law that prohibits access to PHI. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.
We may deny your request to inspect or copy your PHI if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.
To inspect and copy your medical information, you must submit a written request to the Privacy Offi cer whose contact information is listed on the last page of this Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.
Please contact our Privacy Offi cer if you have questions about access to your medical record.

B. The right to request a restriction on uses and disclosures of your PHI. You may ask us not to use or disclose certain parts of your PHI for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notifi cation purposes as described in this Notice of Privacy Practices. Your request must state the specifi c restriction requested and to whom you want the restriction to apply.
We are not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If we agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. Requests for a restriction must be made in writing to our Privacy Offi cer.

C. The right to request to receive confi dential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in another way. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specifi cation of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Privacy Offi cer.

D. The right to request your physician to amend PHI. You may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to fi le a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for an amendment must be in writing and must be directed to our Privacy Offi cer. In this written request, you must also provide a reason to support the requested amendments.

E. The right to receive an accounting. You have the right to request an accounting of certain disclosures of your PHI made by the provider. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to friends or family members involved in your care, or certain other disclosures that we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Offi cer. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that took place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the fi rst accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

F. The right to obtain a paper copy of this notice. Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.

VI. Our Duties

We are required by law to maintain the privacy of your health information and to provide you with this Notice of our privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for the entire PHI that we maintain. If we change our Notice, we will provide a copy of the revised Notice to you personally or will send it via regular mail.

VII. Complaints

You have the right to express complaints to us and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to us by contacting our Privacy Offi cer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for fi ling a complaint.

VIII. Contact Person

The provider’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Offi cer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Offi cer. A complaint directed toward us can be mailed to the Privacy Offi cer by sending it to:

Great Lakes Pain Consultants
4121 Shrestha Drive
Bay City, MI 48706
Attn: Privacy Offi cer

The Privacy Offi cer can be contacted by telephone at (989) 686-6900.