NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH 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 hits notice or our Privacy Practices, please contact:

Privacy Officer

989-753-8453

WHO DOES THIS NOTICE COVER?
This notice describes the privacy practices of our practice including:

All members of our workforce including volunteers, contractors and agents; and any health care professional authorized to enter information into our confidential information

[In your system, subsidiaries or other entities that must follow].

All of these entities, sites and locations are required to follow the terms of this notice. In addition, these entities, sites and locations may share Protected Health Information with each other for treatment, payment and health care operations purposes described in this notice.

PRIVACY and CONFIDENTIALITY OF YOUR PROTECTED HEALTH INFORMATION:
This notice will tell you about the ways in which we may use and disclose Protected Health Information about you. It describes your rights and certain obligations we have regarding the use and disclosure of your personal Protected Health Information. Your personal Protected Health Information is called “Protected Health Information” in the remainder of this notice. We are committed to protecting your Protected Health Information. We will create a record of the care and services you receive at our practice. These records are necessary to provide you with quality care and to comply with legal requirements. Our Notice of Privacy Practices applies to all records of your care created by our practice, whether made by our personnel or other medical professionals. Other medical professionals not associated with our practice may have different policies or notices regarding their use and disclosure of your Protected Health Information. You should consult their notice of privacy practices for information about how other professionals not associated with our practice may sue and disclose your records.

We are required by law to:

• Ensure that Protected Health Information that identifies you is kept confidential and private;
• Provide you with a notice of our legal duties and privacy practices with respect to Protected Health Information about you; and
• Follow the terms of the notice that is currently in effect.

How We May Use and Disclose Your Protected Health Information

The following categories describe different ways that we use and disclose Protected Health Information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.

Treatment:

Treatment: The provision of health care by, or the coordination of health care (including health care management of the individual through risk assessment, case management, and disease management) among health care providers; the referral of a patient from one provider to another; or the coordination of health care or other services among health care providers and third parties authorized by the health plan or individual.

We may use Protected Health Information about you to provide you with medical treatment or services. We may disclose Protected Health Information about you to doctors, nurses, technicians, medical students or other personnel who are involved in taking care of you at our practice. We also may disclose Protected Health Information about you to people outside our practice that may be involved in your medical care after you leave, such as family members, clergy or others w use to provide services that are part of your care.

Payment:

Payment means the activities undertaken by a health plan to obtain premiums or to determine or fulfill its responsibility for coverage and provisions of benefits under the health plan; or a covered health care provider or health plan to obtain or provide reimbursement for the provision of health care.

We may use and disclose Protected Health Information about you sot hat the treatment and services you receive at our practice may be billed and payment collected from you, an insurance company or a third party. We may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you for treatment. We may also tell your health plan about a treatment your are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Operations:

We may use and disclose Protected Health Information about you for the healthcare operations. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use Protected Health Information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine Protected Health Information about many patients to decide what additional services we should offer, what services are not needed and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the Protected Health Information we have with Protected Health Information from other health care provider organizations to compare how we are doing and see where we can make improvements in care and services we offer. We may remove information that identifies you from this set of Protected Health Information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders:

We may use and disclose Protected Health Information to contact you as a reminder that you have an appointment for treatment or medical care.

Treatment Alternatives:

We may use and disclose Protected Health 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 Protected Health Information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care:

We may release Protected Health Information about your to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.

Research:

Under certain circumstances, we may use and disclose Protected Health Information about you for research purposes. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of Protected Health Information, trying to balance the research needs with the patient’s need for privacy of their Protected Health Information. Before we use or disclose Protected Health Information for research, the project will have been approved through this research approval process, but we may, however, disclose Protected Health Information about you to people preparing to conduct a research project. For example, to help them look for patients with specific medical needs, so long as the Protected Health Information they review does not leave our practice. We will almost always ask for your specific 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.

As Required By Law:

We will disclose Protected Health Information about you when required by Federal, state or local law.

To Avert a Serious Threat to Health or Safety:

We may consistent with applicable law and standards of ethical conduct, use and disclose Protected Health Information about you when necessary to prevent or lessen a serious and imminent 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 prevent the threat.

Tissue Donation:
If you are an organ donor, we may release Protected Health Information to organizations that handle tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans:
If you are a member of the armed forces, we may release Protected Health Information about you as required by military command authorities. We may also release Protected Health Information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation:
We may release Protected Health Information about you for worker’s compensation or similar programs. These programs provide benefits for work related injuries or illness.

Public Health Activities:
We may disclose Protected Health Information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report child abuse or neglect;
• To report reactions to medications or problems with products;
• To notify people of recalls of products that they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities:

We may disclose Protected Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes:

If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information about you in response to a court or administrative order. We may also disclose Protected Health Information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement:

We may release Protected Health Information if asked to do so by law enforcement officials:

• In response to a court order, subpoena, court ordered warrant, summons issued by a judicial officer or similar process;
• To identify or locate a suspect, fugitive or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• In good faith, evidence of criminal conduct at our location; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

INDIVIDUAL RIGHTS GRANTED BY HIPAA

You have the following rights regarding Protected Health Information we maintain about you:

Right to Inspect and Copy:

You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care. Usually, this includes medical and billing records but does not include psychotherapy notes, information compiled in reasonable anticipation of or use in a civil, criminal or administrative action or proceeding or Protected Health Information that is subject to or exempt from the Clinical Laboratories Act of 1988.

To inspect and copy Protected Health Information that may be used to make decisions about you, you must submit your request in writing to:

Valley OB-GYN Clinic, P.C.
Attn: Privacy Officer

If you request a copy of the information, we may charge a fee for the costs of copying (including labor), 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 to Protected Health Information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right To Amend

If you feel that Protected Health 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 maintained in the designated record set.

To request an amendment, your request must be made in writing and submitted to:

Valley OB-GYN Clinic, P.C.
Attn: Privacy Officer

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:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
• Is not part of the Protected Health Information kept by or for our practice.
• Is not part of the information which you would be permitted to inspect and copy; or
• 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 Protected Health Information about you that was not made for treatment, payment and health care operations, there are certain exceptions to this right.

To request this list or accounting of disclosures. you must submit your request in writing to:

Valley OB-GYN Clinic, P.C.
Attn: Privacy Officer

Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). We may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred. The accounting must be provided to you no later than 60 days after receipt of your request, unless we utilize the 30-day extension period.

Right to Request Restrictions

You have the right to request a restriction or limitation on the Protected Health Information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do not 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:

Valley OB-GYN Clinic, P.C.
Attn: Privacy Officer

In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. For example, disclosures to a spouse. Either you or we may terminate the restriction upon notification of the other.

Right to Request Confidential Communications:

You have the right to request that we communicate with you about your 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 make your request in writing to:

Valley OB-GYN Clinic, P.C.
Attn: Privacy Officer

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.

You may obtain a copy of this notice in the following manner:

Request that a nurse give you a copy.

CHANGES TO THIS NOTICE

We must change this Notice as necessary and appropriate to comply with changes in the law. We reserve the right to change this notice. We reserve the right to make the revised or changed Notice effective for Protected Health 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 at our practice. The notice will contain on the first page, in the top right hand corner, the effective date. In addition, each time you register for treatment or health care services, we will offer you a copy of the current notice in effect.

COMPLAINTS:

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:

The Privacy Officer

All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

Other uses of Protected Health Information:

Other uses and disclosures of Protected Health Information not covered by this notice of the laws that apply to use will be made only with your written permission. If you provide us permission to use or disclose Protected Health Information about you, you may revoke that permission in writing at any time. If you revoke your permission, we will no longer use or disclose Protected Health Information about you for the reasons covered by your written authorization. You understand that we are unable to take bake any disclosures we have already made with your permission, and that we are required to retain our records of care that we provided to you.