Effective April 14, 2003

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 JAMIE A SIMON,PA-C.

Your medical information is personal. We are 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 about you; and

(3) follow the terms of the Notice that are 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, including some examples. Not every possible use or disclosure is specifically mentioned. However, all of the ways we are permitted to use and disclose your 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. CMG participates in RLS service with other EHRs. Patients can opt out by sending your request to our privacy officer below.

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. You may request that we not release information to your health plan if the PHI pertains solely to an item or service for which you pay us in full out of pocket. This request to not release this information must be in writing and give to us before or at the time the service is rendered. The request should be addressed to Jamie A. Simon, PA-C at our Bay City location.

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 combine medical information about many of our patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, and other office personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning the identify of the specific patients.

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 under the following circumstance: communications describing a health related product or service provided by our office, for your individual treatment, or for case management purposes or for recommending specific alternative treatment

Release of Information to Family/Friends. Our practice may release your medical information to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information. Please note that the person who brings a child for a visit is authorized to receive information relating to that visit, including any follow up care such as a referral to a specialist or medication information.

Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition.

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. For example, disclosure may be required by Workers’ Compensation statutes and various public health statutes in connection with required reporting of certain diseases, child abuse and neglect, domestic violence, adverse drug reactions, etc.

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.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may use your medical information to defend the office or to respond to a court order.

Law Enforcement. We may release medical information about you if required by law when asked to do so by a law enforcement official.

Coroners and Medical Examiners. We may release medical information to a coroner or medical examiner to identify a deceased person or determine the cause of death.

How this Office May not Use your Medical Information

Sale. We will NOT sell any of your medical information without your permission.

Right to Restrict Disclosure of Health Information to Your Health Plan. If you pay 100% out of pocket for any health care item or service, you have the right to request that we not disclose information relating to that item or service to your Health Plan, or to any other source. We will NOT disclose that information if you so request. Any request must be made in writing before or at the time of service, and should be addressed to Jamie A. Simon at our Bay City office.

Any Purpose Not Included. We will NOT use any of your medical information for any reason not described in this policy. We will contact you for your permission for any use of medical information not described in this policy.

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, with the exception of any psychotherapy notes, information related to CPS reporting, or information related to Domestic Violence.

To have a copy of your records sent to another office or provider or to yourself, please complete our authorization form to release medical records available at the front desk. To inspect your medical information, you must submit your request in writing to Jamie A. Simon, PA-C. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances as described above or otherwise required by law. If you are denied access to your medical information, you may request that the denial be reviewed. For information regarding such a review contact Jamie A. Simon, PA-C.

Right to Amend. If you feel that 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 for as long as the information is kept by this office.

To request an amendment, your request must be made in writing and submitted to Jamie A. Simon, PA-C. In addition, you must provide a reason for the amendment.

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) Was not created by us;(b) Is not part of the medical information kept by this office;

(c) Is not part of the information which you would be permitted to inspect and

copy; or

(d) Is accurate and complete to the best of our knowledge, with no contradicting information provided by you.

 

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures this office has made of your medical information. This list of disclosures includes disclosures made for treatment, payment or health care operations. The list of disclosures can include up to the three years preceding the date of the request.

To request this accounting of disclosures, you must submit your request in writing to Jamie A. Simon, PA-C. Your request must state a time period which may not be longer than six years and may not include dates before February 26, 2003.

Right to Request restrictions. You have the right to request a restriction or limitation on the use or disclosure we make of your medical information. We are not required to agree to your request for a restriction (with the exception of notations made above). If we do 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 Jamie A. Simon, PA-C.

Right to Request Confidential Communications. You have the right to request that we communicate with you only in a certain manner. 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 Jamie A. Simon, PA-C. We will accommodate all reasonable requests.

Right to Breach Notification. You will be notified of any breach of unsecured PHI. Exceptions to this notification include the following situations: (1) any unintentional acquisition, access, or use of PHI by a member of our workforce in good faith and within the scope of their duties and such information is not further acquired, accessed, used or disclosed (2) where an inadvertent disclosure occurs by an individual who is authorized to access PHI at a facility operated by CMG or business associate to another similarly situated individual of the same facility, as long as the PHI is not further required, accessed used, or disclosed without authorization; and (3) a disclosure of PHI where a covered entity or business associate has a good faith belief that an unauthorized person to whom disclosure was made would not reasonably have been able to retain such information.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

You may view an electronic copy of this Notice at http://www.cmgsagbay.com/index.php/patient-privacy.

To obtain a paper copy of the Notice, ask the front desk.

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 any revised Notice in this office. Any revised Notice will contain on the first page, in the top right-hand corner, the effective date.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with this office or with the Secretary of the Department of Health and Human Services. To file a complaint with this office, contact:

Jamie A. Simon, PA-C

P.O. Box 2246

Bay City, MI. 48707-2246

989 892-5664 or 989 793-9982

All complaints must be submitted in writing.

THIS OFFICE WILL NOT PENALIZE YOU IN ANY WAY FOR FILING A COMPLAINT.

Other Uses of Medical Information

Other uses and disclosures of your medical information not covered by this Notice of Privacy Practices will be made only with your written authorization. If you provide us such an authorization in writing 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 medical information about you for the reasons covered by your written authorization.

 Version 1, 4/14/03 Version 2, 4/20/11 Version 3, 6/15/213 Version 4, 1/21/14 Version 5, 9/1/14 Reviewed 9/25/205 Revised 5/5/2017