Privacy Policy


OUR LEGAL DUTY  The practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Subtitle D of the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), which is Title XIII of the American Recovery and Reinvestment Act of 2009.  We are required by applicable state and federal law to maintain the privacy of your health information.  We are also required to provide you with this Notice about our privacy practices, our legal duties, and your rights concerning your health information.  We must follow the privacy practices that are described in this Notice while it is in effect.  This Notice becomes Effective on 09-13-2013, and will remain in effect until the Practice changes it.  

We reserve the right to change this notice at any time.  We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we may receive from you in the future.  We will post a copy of the current notice in the Practice.  You may request a copy of this Notice at any time.  For more information about our privacy practices, or for additional copies of this Notice, you may contact us using the information at the end of this Notice.


USES AND DISCLOSURE OF HEALTH INFORMATION  The following categories describe different ways that we use and disclose protected health information that we have and share with others.

Treatment – We use and disclose medical information about you to provide you with current or prospective medical treatment or services.  Different areas of the Practice also may share medical information about you including your record(s), prescriptions, request of lab work and x-rays.  We also may disclose medical information about you to people outside the Practice who may be involved in your medical care after you leave the Practice.

Payment – We may use and disclose medical information about you for services and procedures so they may be billed and collected from you, an insurance company, or any other third party.

Health Care Operations – We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment, quality improvement, staff qualification and performance evaluations, practitioner and provider performance, training purposes of helping us to comply with our legal requirements, to auditors to verify our records, to billing companies to aid us in this process and the like.  We shall endeavor, at all times when business associates are used, to advise them of their continued obligation to maintain the privacy of your medical records.

Your Authorization – In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or disclose it to anyone for any purpose.  If you have provided us with an authorization to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made while your authorization was in effect. 

To Your Family and Friends – We must disclose your health information to you.  We may disclose your health information to a family member, friend or other person to the extent necessary to help with your health care, or payment for your health care, but only if you agree that we may do so (or as authorized by a legal mandate).

Persons involved In Care – We may use or disclose your health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or other person responsible for your care, of your locations, your general condition, or death.  If you are present, then prior to use and disclosure of your health information, we will provide you with the opportunity to object to such uses or disclosure.  In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only the health information that is directly relevant to the person’s involvement in your healthcare.  We will also use our judgment and 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.

Marketing & Research –We will not use your health information for marketing communications or research purposes without your written authorization.

Required by Law – We may use or disclose your health information when we are required to do so by law, to local, state, or federal agencies.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the facility or official, for the provision of healthcare, or the protection of health, safety and security of the institution.

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, or domestic violence or the possible victim of other crimes.  We may disclose your health information to the extent necessary to avert a serious threat to your health or safety of others.  

Appointment and Patient Recall Reminders – We may use and disclose your health information to provide you with appointment reminders (such as a phone call, phone messages, voicemail, or letters).



Right to Inspect and Copy – You have the right to look at or get copies of your health information.  Upon proof of an appropriate legal relationship, records of others related to you or under your care (guardian or custodial) may also be disclosed.  To obtain a copy of your medical record, you must submit your request in writing to our Compliance Officer, using the contact information given below.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies (tapes, disks, etc.) associated with your request. 

We may deny your request to obtain a copy in certain, very limited circumstances.  If you are denied access to medical information, you may request that our Compliance Committee review the denial.  Another licensed health care professional chosen by the Practice will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome and recommendations from that review.

Right to Amend – You have the right to request an amendment to your health information for as long as the Practice maintains your medical record.  Your request must be submitted in writing, along with your intended amendment and a reason that supports your request to amend.  The amendment must be dated and signed by you and notarized.

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 my deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for the Practice;
  • Is not part of the information which you would be permitted to inspect and copy; or is inaccurate and incomplete.

Right to an Accounting of Disclosure – You have the right to request an “accounting of disclosures” of your health information that we make to others for purposes other than your treatment, payment, or health care operations and certain other activities.  To request this list, you must submit your request in writing.  Your request must state a time period not longer than six (6) years back and may not include dates before 04-14-03.  Your request should indicate in what form you want the list (for example, on paper, electronically).  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Notification in the Case of Breach – You have the right to written notification within sixty (60) days of any breach of your unsecured protected health information, as defined by HITECH.  Notification under this section shall include, to the extent possible:  1) A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known; 2) A description of the types of unsecured protected health information that were involved in the breach; 3)The steps you should take to protect yourself from potential harm resulting from the breach; 4) A brief description of what we are doing to investigate the breach, mitigate losses, and protect against any further breaches; and 5) Contact procedures for you to ask questions or learn additional information.

Right to Request Restrictions – You have the right to request a restriction or limitation to the use or disclosure of your health information for treatment, payment or health care operations.  You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care of the payment for your care ( a family member or friend) unless otherwise required by law.

We are not required to agree to your request and we may not be able to comply with your request.  If we do agree, we will comply with your request except that we shall not comply, even with a written request, if the information is excepted from the consent requirement or we are otherwise required to disclose the information by law.

You must make your request in writing and in your request indicate:

  • 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, (e.g., disclosures to your children, parents, spouse, etc.)

Right to Request Alternative 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 can ask that we only contact you at work or by mail, that we not leave voicemail or e-mail, or the like.

To request alternative communications, you must make your request in writing and must specify how or where you wish us to contact you.  We will not ask you the reason for your request.  We will accommodate all reasonable requests, however, we may deny your request under certain circumstances. 

Right to a Paper Copy of This Notice – You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.



If you want more information about our privacy practices or have questions or concerns, please contact us.

If you believe your privacy rights have been violated, or disagree with a decision we made about access, amendment, or restriction of the use of your health information, you may file a written complaint with the Practice using the contact information stated below.  You also may file your complaint with HHS upon request. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you.  We support your right to the privacy of your health information.  You will not be penalized for filing a complaint.

TELEPHONE:  (269) 323-1527  FAX:  (269) 323-1670

ADDRESS:  3801 Glenkerry Ct  Portage, MI 49024


Date of Last Revision:  01-09-2014                                              Effective Date:  09-13-2013