Patient Privacy

We understand that health information about you is personal and we are committed to protecting your information. We have developed policies and procedures to protect your health information. We have trained workforce members, and have sanctions for failure to comply with these policies and procedures. Washington Family Medicine creates a record of the care and services you receive. We need this record to provide care, for payment, for health care business operations, and to comply with certain legal requirements. This notice applies to all of the records of your care created or received by Washington Family Medicine. This notice describes Washington Family Medicine’s practices within our office.

We are required by law to:

• Make sure health information that identifies you is kept private
• Make this notice available to you, describing our legal duties and privacy practices with respect to
  health information about you
• Follow the terms of the notice that is currently in effect
• Notify you if any health information about you was not protected by our employees or our business
  associates, and was accessed by an unauthorized person

How Washington Family Medicine may use and disclose health information about you:

We may use technology to share health information including, but not limited to, faxing and EHR (electronic health record) transmissions.

Treatment
Disclosure to Providers
We may use and disclose health information about you to doctors/providers in our workforce involved in your care. We may share health information about you in order to coordinate your healthcare.

Disclosure to Family and Friends
We may disclose health information about you for continuity of care to people outside of our office, such as family members or designated friends if we obtain your verbal permission, or we give you an opportunity to object, and you do not do so. We may also disclose health information if we can infer from circumstances, that you would not object. For example, if you bring a spouse or a friend into the exam room with you, we may assume you agree to our disclosure of your health information. In situations where you are not capable
of giving consent because you are not present, incapacitated, or it’s a medical emergency, we may determine
that a disclosure to your family or friend is in your best interest. In that situation, we will only disclose information that is relevant to the situation.

Disclosure to Others
Other people we may disclose your information to include clergy, health care providers, or community
services, such as disaster relief agencies. In addition we may disclose health information to the manufacturer
of an implant, device, or drug used in your treatment to the Food and Drug Administration.

Payment
We may disclose health information about you to your insurance company and its agents so services you receive may be billed and paid. We may also disclose health information such as diagnosis, types of procedures, testing or treatment performed, as well as provide copies of your health record to your insurance company or its agents, to obtain prior approval, or to determine whether your insurance will cover tests, treatments, or procedures.

Health Care Business Operations
We may use and disclose health information about you for health care business operations such as legal,
accounting, claims processing, or utilization review. These uses and disclosures are necessary to make sure
that all of our patients receive quality care.

Examples of ways we may use your health information:

• Evaluation of staff treating you
• Decision to offer additional services
• Evaluation of office efficiency
• Determine success of new treatments

Examples of ways insurance carriers and other providers may use your health information:

• Provide or improve care
• Reduce costs
• Coordinate and manage health care and services
• Train staff
• Comply with the law

Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services

We may use and disclose health information to contact you as a reminder that you have an appointment for a
visit, treatment or testing, to tell you about or recommend possible treatment options, alternatives, or health
related benefits or services that may be of interest to you.

Fundraising Activities
Washington Family Medicine will not use health information about you to communicate with you in a effort to raise money. On occasion, we may accept voluntary donations towards a cause, such as cancer research, but on no occasion will you ever be contacted in an effort to raise money.

To Prevent a Serious Threat to Health or Safety
We may use and disclose health information about you 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 done to help
prevent the threat.

Authorization Required
We will only use your health information for purposes specifically allowed by Federal or State laws or regulations unless you provide written authorization. The following types of disclosures require your written authorization: disclosure of psychotherapy notes; disclosures for marketing purposes; disclosures that constitute a sale of protected health information. Other uses and disclosures of health information not covered by this notice, law, or regulation will be made only with your written authorization. If you give us permission to use or disclose health information about you, you may at any time revoke, in writing, that permission for future uses and disclosures. You understand that any disclosures we have already made with your permission cannot be taken back.

Disclosures as required by law or regulation

• We may disclose health information, including individually identifiable health information about you as required by State or Federal laws and regulations relating to any or all of the following, as such may apply to you:
• Community/Public health activities and reports such as disease control, abuse or neglect, and health
  and vital statistics.
• Administrative agency oversight for such things as audits, investigations, licensure, or determining cause of death.
• Court Order or other legal processes related to law enforcement or national security activities.
• Military and Veteran reporting on members of the armed forces of U.S. or foreign military.
• Organ and Tissue Donation and Transplant reports as required by regulatory organizations.
• Workers’ Compensation or other rehabilitative activities reporting as required by law or to insurers in
  order to provide benefits for work related or victim injuries or illnesses.

In addition, we may follow more stringent Michigan law, for example minors may seek treatment without parental consent for certain conditions; however, we may notify the parents or guardians of the treatment without the minor’s consent.

Your rights regarding health information about you

Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care business operations. We are not required by federal regulation to agree to your request. If we do agree, we will comply with your request unless the information is
needed to provide emergency treatment. To request restrictions, you must make your request in writing to Washington Family Medicine. In your request you must tell us what information you want to limit; whether you want to limit our use, disclosure or both; and to whom you want the limits to apply, for example, disclosures to your spouse.

Out-of-Pocket Services
You have the right to pay in full for a service, rather than bill it to your insurance. If you have paid out-ofpocket for a service, you have the right to restrict disclosure of your health information about that service or item, which was not billed to your insurance, and which was paid in full by you or another individual. This request must be made in writing to Washington Family Medicine.

Right to Inspect and Copy
You have the right to access, inspect and receive a copy of your health information that we create or receive about you. Usually, this includes medical and billing records. To inspect and receive a copy of health information, you must submit your request in writing to Washington Family Medicine. We will charge a fee for the costs of copying, mailing or other supplies and labor associated with your request as allowed by Michigan law or regulation. Electronic copies of your health information may be available if a system is in place to accommodate such a request, while maintaining the privacy of your records.

Right to Amend
If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend the information by adding a statement to your health information. To request an amendment, your request must be made in writing and submitted to Washington Family Medicine. 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; Is not part of the health information kept by or for Washington Family Medicine; 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 health information about you. To request this list of accounting of disclosures, you must submit your request in writing to Washington Family Medicine. Your request must state a time period which may not be longer than 6 years. Your request must be for dates after April 14, 2003. Your request must state in what form you would like the list provided (example: paper or electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list.

Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example you may ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Washington Family Medicine. Your request must specify how or where you wish to be contacted.

Breach of unsecured PHI
In the event that your protected health information has been breached, you will be notified in writing within 30 days of discovery. In the event that more than 500 individuals have been affected, the proper authorities, as well as the media will be notified, as required by law.

Right to a Copy of This Notice
You have the right at any time to a paper or electronic copy of this notice. A paper copy may be provided by any of our staff members. An electronic copy may be found on our website: WFMedicine.com.

Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you, as well as any information we receive in the future. At any time, you may receive a copy of the current notice in effect. The current effective date will be posted on the first page, in the top right-hand corner.

Complaints
If you believe your privacy rights have been violated, you may file a written compliant to Washington Family Medicine, or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

Definition of “Health Information”
Health [patient] Information (PHI) is any information, whether oral or recorded in any form or medium, that: Is created or received by a health care provider, health plan, public heath authority, employer, life insurer, school or university, or health care clearinghouse; and Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.