Your information is important and confidential. Our ethics and policies require that your information be held in strict confidence.
UNDERSTANDING YOUR HEALTH RECORD
We maintain protocols to ensure the security and confidentiality of your personal information, and we are committed to protecting medical information about you. Within our practice, access to your information is limited to those who need it to perform their jobs. We responsibly protect your health information. This notice describes your rights as they relate to your protected health information.
Each time you visit Michigan Clinic for Facial Pain, PLC, a record of your visit is made. Typically, this record contains your symptoms, diagnoses, treatment and our plan for future care or treatment. This health/medical record serves as a basis for planning your care and treatment, a means of communication among those health professionals contributing to your care, and a tool by which we can assess and continually work to improve the care we render and outcomes we achieve. Understanding what is in your record and how your health information is used helps you ensure its accuracy, better understand who, what, when, where and why others may access your health information and make more informed decisions when authorizing disclosure to others.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make these changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.
OUR RESPONSIBILITIES
Michigan Clinic For Facial Pain, PLC, is required to maintain the privacy of your health information, provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, abide by the terms of this notice, notify you if we are unable to agree to a requested restriction and accommodate reasonable requests you may have to communicate your health information to other health practitioners or insurance companies.
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will charge you a reasonable, cost-based fee for expenses such as copies and staff time. You may also request access by sending a letter to the address at the end of this notice. If you request copies, we will charge you $25-$50 for staff time to locate and copy your health information, plus postage should you request the copies be mailed to you.
Disclosure Accounting: You have the right to receive a list of instances in which we, or our business associates, disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions but, if we do, we will abide by our agreement (except in an emergency).
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment and healthcare operations. For example:
Treatment: We may use and/or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and/or disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and/or disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, and conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it, in writing, at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use and/or disclose your health information when we are required to do so by law.
Appointment Reminders: We may use and/or disclose your health information to provide you with appointment reminders (e.g., voicemail messages, postcards or letters).
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will make a determination based on our professional judgment and disclose only that health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.
To Your Family & Friends: We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety, or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence and other national security activities. Under certain circumstances, we may disclose protected health information of an inmate or patient to a correctional institution or law enforcement official having lawful custody.
If you want more information about our privacy practices or have questions or concerns, please contact:
Laila Bouchar, Business Manager
Michigan Clinic for Facial Pain, PLC
3144 John R Road, Suite 100
Troy, Michigan 48083
248-519-1100 (phone)
248-519-0300 (fax)
