Notice of Privacy Practices

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.

Our Legal Duty

We are required by law to protect the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties and your rights concerning your health information. We will follow the privacy practices that are described in this Notice while it is in effect. This Notice is effective beginning April 14, 2003 and will remain in effect until we replace it.

We reserve the right to change our policies and the terms of this Notice at any time. Any changes we make will be effective for all of the information we maintain, including the information we created or received before we made the changes. When we do, this Notice will be changed and the new Notice will be posted in the waiting area.

You can request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, contact us using the information listed at the end of this Notice.

Uses and Disclosures of Your Health Information

We use and disclose health information about you for treatment, payment, and healthcare operations.

This means that we may use or disclose your health information:

• To a physician or other healthcare provider who is providing treatment to you
• To obtain payment for services that we provide to you 
• To assess the care that was provided and monitor the quality and effectiveness

We will also use and disclose your health information for reasons listed below: 

• When you specifically request and authorize us to do so in writing. If you do so, you can revoke (or cancel) your authorization at any time by submitting your request in writing. Once you revoke the authorization, no future uses or disclosures will occur related to your original authorization request. Without your written authorization we will not use or disclose your information except as listed in this Notice.
• We may release your health information to a friend or family member who is involved in your care;or who assists in taking care of you unless you object. If you are incapacitated or in emergency circumstances, we will release your health information if we believe, by using our professional judgment and experience, it is in your best interest.
• We will contact you to provide appointment reminders via phone or mail. We may leave messages on your answering machine for these reminders.
• We will share your health information with our business associates. A business associate is a company that provides certain services to our practice. To protect you, we have signed agreements in place that require our business associates to keep your information private.
• When we are required by law to do so.
• When required for certain public health activities, such as disease control or public health investigations.
• If we believe that you are a possible victim of abuse, neglect, domestic violence, or the victim of other crimes. We will disclose information if we determine the disclosure is necessary to prevent serious harm to you or others.
• When law enforcement or federal officials request information or as required by certain judicial or administrative court proceedings.
• For research purposes when the research has been approved by an institutional review board that has reviewed proposals and established protocols to ensure the privacy of your health information.
• When required for certain.FDA investigations and activities, such as investigations of product defects, or to permit product recalls, repairs or replacements.
• To a coroner or funeral director if necessary to complete their legal duties.
• If you are an organ, eye or tissue donor, we will disclose information to facilitate your donation.
• When authorized by and to the extent necessary to comply with workers' compensation laws.

Patient Medical Record Rights

In most cases, you have the right to look at or get copies of your health information and you may do so by completing our request form. If you request copies, we will charge you a reasonable cost-based fee for the copies that are made. If you would like to look at your health information, a time will be scheduled for you do so in the company of an office staff member and you will be charged a reasonable fee to cover the costs associated with such appointment. You also have a right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment or for healthcare operation purposes after April 14, 2003. If you request this information more than once in a 12 month period, we will charge you a reasonable, cost-based fee for fulfilling any additional requests. 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 with your restrictions, but if we do, then we will abide by our agreement (except when required by law or in an emergency). If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. You must request this in writing and we may deny your request in certain circumstances. You have the right to receive confidential communication from us. You must submit a written request to have us communicate with you about your health information by alternate means or at an alternate location. If you received this notice electronically, you have the right to receive a paper copy.

Questions and Complaints

If you would like more information about our privacy practices or have questions, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information, or in response to a request you made to restrict or amend the use or disclosure of your health information, or if we cannot accommodate your request to communicate with you by alternate means or at an alternate location, you may file a written complaint using the contact information below.

Attention: Administration
Blake Woods Medical Park Surgery Center
2775 Blake Road
Jackson, MI 49201 (517)787-2906

U.S. Department of Health and Human Services,Department of Civil Rights

We will provide you with the address upon request.

Investigations & National Accounts lead

Whitney Smith

Compliance & Patient Safety Data Reporting lead of AAAASF

Rosa Anderson
Phone: (888) 545-5222
Email: info@aaaasf.org

Michigan Department of Community Health 1-800-882-6006

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. SSC057 (2/07, REV 061009 v.2, 091609 v.3)IM-00107