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Effective
date of Notice: 04/14/03 Phone:
734-712-1020 Fax:
734-712-3218 Contact
Person: Stephanie Smith 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. We
respect our legal obligation to keep your health information private. We
are obligated by law to give you notice of our privacy practices. This
Notice describes how we protect your health information and what rights
you have regarding this information. If you have questions about this
Notice, please contact the office contact person shown above. TREATMENT,
PAYMENT, AND HEALTH CARE OPERATIONS The
most common reason why we use or disclose your health information is for
treatment, payment or health care operations. Examples of how we use or
disclose information for treatment purposes are: setting up an appointment
for you; performing a physical examination; performing diagnostic tests
such as CAT scans, X-rays, and lab work; prescribing medications and
faxing prescriptions or calling them into the pharmacy to be filled;
referring you to another doctor or clinic for additional or specialist
services; or getting copies of your health information from another
professional that you may have seen before us. Examples of how we use or
disclose your health information for payment purposes are: asking you
about your health insurance coverage or other sources of payment;
preparing and sending bills or claims; and collecting unpaid amounts
(either ourselves or through a collection agency or attorney).
"Health care operations" means those administrative and
managerial functions that we have to do in order to run our office.
Examples of how we use or disclose your health information for health care
operations are: financial or billing audits; internal quality assurance;
personnel decisions; participation in managed care plans; defense of legal
matters; business planning; and outside storage of our records. We may
release medical information about you to a friend, family member or member
of the clergy who is involved in your medical care, unless you tell us not
to do so. We routinely use your health information within our office for
these purposes without any special permission. If we need to disclose your
health information outside of our office for these reasons, we will ask
you for special written permission. USES
AND DISCLOSURES WITHOUT PERMISSION FOR OTHER REASONS In
some limited situations, the law allows or requires us to use or disclose
your health information without your permission. Not all of these
situations will apply to us; some may never come up at our office at all.
Such uses or disclosures are:
APPOINTMENT
REMINDERS We
may call or write to remind you of a scheduled appointment or to notify
you that it is time to make a routine appointment. We may also call or
write to notify you of other treatments or services available at our
office that might help you. OTHER
USES AND DISCLOSURES We
will not make any other uses or disclosures of your health information
unless you sign a written "authorization form." Federal law
determines the content of an "authorization form". Sometimes,
you may initiate the process if it is your idea for us to send your
information to someone else. Typically in this situation you will give us
a properly completed authorization form or you can use one of ours. If we
initiate the process and ask you to sign an authorization form, you do not
have to sign it. If you do not sign the authorization, we cannot make the
use or disclosure. If you do sign the authorization, you may revoke it at
any time unless we have already acted in reliance upon it. Revocations
must be in writing. Send them to the office contact person named at the
beginning of this Notice. YOUR
RIGHTS REGARDING YOUR HEALTH INFORMATION The
law gives you many rights regarding your health information. You can:
COMPLAINTS If
you think that we have not properly respected the privacy of your health
information, you may complain to us or to the U.S. Department of Health
and Human Services, Office for Civil Rights. We will not retaliate against
you if you make a complaint. If you want to complain to us, send a written
complaint to the office contact person at the address, fax or e-mail shown
at the beginning of this Notice. If you prefer, you can discuss your complaint
in person or by phone. FOR
MORE INFORMATION If
you want more information about our privacy practices, call or visit the
office contact person at the address or phone number shown at the beginning
of this Notice. ACKNOWLEDGMENT
OF RECEIPT I
acknowledge that I received a copy of Ann Arbor Hematology Oncology Associates'
Notice of Privacy Practices. Patient
Name Patient (or Personal Representative) Signature
Date
Ann
Arbor Hematology Oncology Associates, P.C. |
