WHAT EVERY PATIENT SHOULD KNOW.
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. If you have any questions about this Notice, please contact our Privacy Officer, Dr. Mark Walker at (269) 781-1183.
PROVIDERS COVERED BY THIS NOTICE
Mansion Street Women’s Health, PLLC is required by law to maintain the privacy of your health information, to provide you with this Notice of our legal duties and privacy practices, and to abide by the terms of this Notice currently in effect. We may share your health information for purposes of providing you with treatment, obtaining payment for medical services, and for health care operations. Examples of sharing information for purposes of treatment, payment, and health care operations are described below.
OUR PLEDGE TO YOU:
We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care, bill for your care, and comply with legal requirements. This Notice applies to all of the records of your care that we maintain, whether made by our staff, or by the physicians and other health care professionals working with us.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.
Our doctors, nurses, and other health care professionals may use health information about you to provide you with health care treatment or services. We may also disclose health information about you to others who are involved in taking care of you. For example, we may send health information about you to a physician specialist as part of a referral. Or, we may share information with a local nursing home in order to continue your care. We may use and disclose health information about you to obtain payment for the treatment and services you receive from us or from the doctors and other health care professionals that treat you. For example, we may send billing information to your insurance company or Medicare. We may use and disclose health information about you to support our health care operations. For example, we may use health information to review the treatment and services we provide to you and to evaluate the performance of our staff in caring for you. Unless you object, we may disclose information to a family member or other person responsible for your care about your condition, status, and location. Unless you tell us otherwise, we will include your name, location, your general condition (good, fair, etc.), and religious affiliation in our patient directory and make this information available to anyone who asks for you by name. Unless you object, we may disclose this information to a member of the clergy. We may use and disclose health information to contact you for an appointment reminder, to tell you about healthrelated services or to recommend possible treatment options or alternatives that may be of interest to you. We may contact you about supporting our fund raising efforts. Subject to certain requirements, we may use or disclose health information about you without your prior authorization for other reasons:
We may give out health information about you for public health purposes; to report abuse or neglect; for health oversight reviews; in research studies, so long as provision is made for the protection of your health information; to medical examiners; for funeral arrangements and organ donation; in response to special law enforcement requests, valid judicial or administrative orders, or for authorized national security and intelligence activities; for workers’ compensation purposes; to avert a serious threat to your health or safety or those of the public or another person; and when required by law (for example, state law requires certain reports to cancer registries). If you are or were a member of the armed forces, we may release information about you as required by military command authorities or the Department of Veterans Affairs. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. We must also release your health information when required by the Department of Health and Human Services to investigate our compliance with the privacy laws. Both federal and state laws protect your health information. In situations where both laws apply, we will comply with the law that is most protective of your health information and/or gives you additional rights. For example, in some situations Michigan law gives more protection to information contained in mental health records. For any other purpose not covered by this Notice, we will ask for your written authorization before using or disclosing your health information. You may revoke this authorization at any time by notifying us in writing, except to the extent we have taken an action in reliance on your authorization.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.
You have the right to request in writing that you inspect and obtain a copy of the health information we maintain. We may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. In certain circumstances, we may deny your request. You may request that this denial be reviewed. If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend your health information. The request must be in writing, and should state the reason for the amendment and the specific information to be amended. You have the right to make a written request for a list of disclosures we have made of your health information. This list will not include disclosures made for treatment, payment, and health care operations, to your family, or those disclosures you authorized. You have the right to request a restriction on the health information we use or disclose about you, including a right to request restrictions on disclosures to family members or friends. You must submit this request in writing. We are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, or we are otherwise required by law to make a disclosure. You have the right to request that confidential communications with you be made in an alternative manner or location. This request must be in writing, but you do not need to state the reason for your request. For example, you may ask us to send information to your work address instead of your home address, or in a blank envelope with no distinguishing marks. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
All written requests should be submitted to our Privacy Officer, Dr. Mark Walker at 215 East Mansion Street, Suite 3D, Marshall, MI 49068.
COPIES OF NOTICE AND CHANGES
You have the right to obtain a paper copy of this Notice at any time, upon request, even if you have agreed to accept this Notice electronically. You may also obtain a copy of this Notice at our website, www.mansionstreetwh.com
We reserve the right to change this Notice, and to make the changed Notice effective for health information we already have about you as well as any information we receive in the future. Upon your request, we will provide you with any revised Notice. A revised Notice will also be posted in waiting areas throughout our facilities and at our website, www.mansionstreetwh.com
If you are concerned that your privacy rights may have been violated or you disagree with a decision we make about your health information, you may file a complaint with our Privacy Officer, Dr. Mark Walker. You may also send a written complaint to the U.S. Department of Health and Human Services. Our Privacy Officer, Dr. Mark Walker can provide you with the address.
Under no circumstances will we ever ask you to waive your rights under this Notice or retaliate against you in any manner for filing a complaint.
This Notice was published and became effective on February 1, 2014.
Patient Rights--These rights apply to our patients and/or their legal representatives.
- Be informed of their rights prior to the institution or discontinuance of care.
- Receive information in a language that can be understood.
- Be given considerate and respectful care in a safe setting, without discrimination.
- Personal privacy in a confidential and secure environment, in accordance with HIPAA regulations.
- Exercise civil and religious liberties.
- Be informed of choices.
- Participate in the plan of care, make decisions regarding that care, and accept or refuse treatment, the risks, benefits, other options and prospects for recovery.
- Participate in ethical questions, conflict resolution, organ donation, withdrawal of life-sustaining treatment and withholding resuscitation.
- Effective pain management.
- The use of advance directives.
- Access personal medical records.
- Protective services.
- Be informed of and refuse to participate in human experimentation or other research.
- Charges and billing information.
- Be informed of unanticipated outcome.
- A patient is responsible for following the office rules and regulations affecting patient care and conduct.
- A patient is responsible for providing a complete and accurate medical history.
- A patient is responsible for making it known whether he or she clearly comprehends a contemplated course of action, consents to it, and understands the actions expected.
- A patient is responsible for following the recommendations and advice prescribed in a course of treatment by the physician.
- A patient is responsible for providing information about unexpected complications that arise in an expected course of treatment.
- A patient is responsible for being considerate of the rights of other patients and office personnel and property
- A patient is responsible for providing the office with accurate and timely information concerning his or her sources of payment and ability to meet financial obligations.
- A patient is responsible for any personal property brought into the office.
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
By signing below, I acknowledge that I have received Mansion Street Women’s Health, P.L.L.C.’s Notice of Privacy Practices. This document may be scanned into an electronic format and such printed copy of the electronic record shall be deemed an original.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.