Dermatology Center of
Grand Rapids, PC
NOTICE OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a Result of
the Health Insurance Portability and Accountability Act of 1996
PLEASE REVIEW THIS NOTICE CAREFULLY
A. OUR COMMITMENT TO YOUR PRIVACY
Each time you visit our office or another health care provider
contacts us concerning your medical needs, a record is made
by our office. We are dedicated to maintaining the privacy of
your record, which we will call “individually identifiable
health information” (IIHI). We
are required by law to give you this notice. It will tell
you about the ways in which we may use your IIHI and describes
your rights and our obligations regarding the use and disclosure
of that information.
We reserve the right to change this Notice of Privacy Practices
and make the revised or changed notice 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 our current
Notice in our offices in a visible location at all times, and
you may request a copy of our most current Notice at any time.
B. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
1. Treatment. We may use your IIHI to provide
medical services to you. Our staff involved in your care will
have access to your IIHI in order to treat you or to assist
others in your treatment. We may also disclose your IIHI to
other health care providers for purposes related to your treatment,
such as the pharmacy, laboratory or pathologist.
2. Payment. We may use and disclose your IIHI
in order to bill and collect payment for the services and items
you may receive from us. For example, we may contact your health
insurer to verify your coverage and we may provide your insurer
with details regarding your treatment to determine if your insurer
will pay for your treatment. Also, we may use your IIHI to bill
you directly for services and items. We may disclose your IIHI
to other health care providers and entities to assist in their
billing and collection efforts.
3. Health Care Operations. We may review and
use IIHI in order to assess the office and make sure that you
and our other patients receive quality care. For example, we
may use your health information to evaluate the performance
of our staff in caring for you. This information will then be
used by us in an effort to continually improve the quality and
effectiveness of our services.
4. Appointment Reminders and Information on Treatment
Alternatives. We may contact you to provide appointment
reminders, information concerning treatment alternatives or
other health-related benefits and services that may be of interest
5. Disclosures Required By Law. We will use
and disclose your IIHI when we are required to do so by federal,
state or local law.
6. Persons Involved in Your Care. We may disclose
your health information that is directly relevant to your care
to individuals you wish to receive such information, including
family members, relatives, close personal friends, or other
persons you identify. Before we do so, we will ask you, and
follow your instructions, as to whether to make such disclosures,
unless they are in the examination room with you.
C. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL
1. Public Health Risks and Health Oversight.
We may disclose your IIHI to public health authorities that
are authorized by law to prevent or control disease, injury
or disability; or to report deaths, suspected abuse or neglect,
non-accidental physical injuries, reactions to medications or
problems with products. We may disclose your IIHI to a health
oversight agency for activities authorized by law. Oversight
activities can include investigations, inspections, audits,
surveys, licensure and disciplinary actions; civil, administrative,
and criminal procedures or actions; or other activities necessary
for the government to monitor government programs, compliance
with civil rights laws and the health care system in general.
2. Lawsuits and Similar Proceedings. We may
use and disclose your IIHI in response to a court or administrative
order, if you are involved in a lawsuit or similar proceeding.
We also may disclose your IIHI in response to a discovery request,
subpoena, or other lawful process by another party involved
in the dispute, but only if we have made an effort to inform
you of the request or to obtain an order protecting the information
the party has requested.
3. Law Enforcement. We may release IIHI if
asked to do so by a law enforcement official under certain circumstances:
1) regarding a crime victim in certain situations, if we are
unable to obtain the person’s agreement, 2) concerning
a death we believe has resulted from criminal conduct, 3) regarding
criminal conduct in our offices, 4) in response to a warrant,
summons, court order, subpoena or similar legal process, 5)
in an emergency to report a crime (including the location or
victim of the crime, or the description, identity or location
of the perpetrator.)
4. Deceased Patients. We may release IIHI
to a medical examiner or coroner to identify a deceased individual
or to identify the cause of death. If necessary, we also may
release information in order for funeral directors to perform
5. Serious Threats to Health or Safety. We
may use and disclose your IIHI when necessary to reduce or prevent
a serious threat to your health and safety or the health and
safety of another individual or the public. Under these circumstances,
we will only make disclosures to a person or organization able
to help prevent the threat.
6. Military. We may disclose your IIHI if
you are a member of U.S. or foreign military forces including
veterans and if required by the appropriate authorities.
7. National Security. We may disclose your
IIHI to federal officials for intelligence and national security
activities authorized by law. We also may disclose your IIHI
to federal officials in order to protect the President, other
officials or foreign heads of state, or to conduct investigations.
8. Inmates. We may disclose your IIHI to
correctional institutions or law enforcement officials if you
are an inmate or under the custody of a law enforcement official.
Disclosure for these purposes would be necessary: (a) for the
institution to provide health care services to you, (b) for
the safety and security of the institution, and/or (c) to protect
your health and safety or the health and safety of other individuals.
9. Workers’ Compensation. We may release
your IIHI for workers’ compensation and similar programs.
10. Business Associates: Certain of our business
operations may be performed by other businesses, referred to
as “Business Associates.” We may need to disclose
your IIHI so that they can perform the job we’ve asked
them to do. To protect you, we require our business associates
to appropriately safeguard your health information.
D. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI that we maintain
1. Confidential Communications. You have the
right to request that we communicate with you about your health
and related issues in a particular manner or at a certain location.
For instance, you may ask that we contact you at home rather
2. Requesting Restrictions. You have the right
to request a restriction or limitation on the IIHI we use or
disclose for treatment, payment or operations.
3. Inspection and Copies. You have the right
to inspect and obtain a copy of the IIHI that may be used to
make decisions about you, including patient medical records
and billing records. This does not include psychotherapy notes
or information compiled in reasonable anticipation of certain
civil, criminal or administrative proceedings.
4. Amendment. You may ask us to amend your
health information if you believe it is incorrect or incomplete,
and you may request an amendment for as long as the information
is kept by or for our practice. To request an amendment, your
request must be made in writing and submitted to the privacy
officer. You must provide us with a reason that supports your
request for amendment. We will deny your request if you fail
to submit your request (and the reason supporting your request)
in writing. Also, we may deny your request if you ask us to
amend information that is in our opinion: (a) accurate and complete;
(b) not part of the IIHI kept by or for the practice; (c) not
part of the IIHI which you would be permitted to inspect and
copy; or (d) not created by us unless the individual or entity
that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our patients
have the right to request an “accounting of disclosures.”
This is a list of certain non-routine disclosures we have made
of your IIHI for non-treatment, non-payment or non-operations
purposes. Use of your IIHI as part of the routine patient care
in our practice is not required to be documented. For example,
the doctor sharing information with the nurse; or the billing
department using your information to file your insurance claim.
All requests for an “accounting of disclosures”
must state a time period, which may not be longer than six (6)
years from the date of disclosure 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 costs involved and you may
withdraw your request before you incur any costs.
6. Right to Provide an Authorization for Other Uses
and Disclosures. We will obtain your written authorization
for uses and disclosures that are not identified by this notice
or permitted by applicable law. This may be revoked at any time
in writing after which, we will no longer use or disclose
your IIHI for the reasons described in the authorization. Please
note, we are required to retain records of your care.
7. Right to File a Complaint. If you believe
your privacy rights have been violated, you may file a complaint
with the practice’s privacy officer or with the Secretary
of the Department of Health and Human Services. All complaints
must be submitted in writing. You will not be penalized
for filing a complaint.
If you have any questions or concerns, or you wish
to exercise any of the above rights please mail
or deliver a signed letter detailing your request to our privacy
officer. We encourage you to call first so that we can help
you be as specific as possible with your request. We will promptly
provide you with any forms needed to process your request.
Dermatology Center of Grand Rapids, PC
426 Michigan St. Suite 201
Grand Rapids, MI 49503
616-459-8209 Ext. 1116