As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of medical information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your medical record. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

This office is required by law to:

  • make sure that medical information that identifies you is kept private;
  • give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
  • follow the terms of the Notice that is currently in effect.

The terms of this notice apply to all records containing your medical information that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Robert M. Soderstrom, M.D, Attn: Audrey, G-5131 W. Bristol Rd., Flint, MI 48507 (810) 733-2090

C. WE MAY USE AND DISCLOSE MEDICAL INFORMATION IN THE FOLLOWING WAYS

The following describes the different ways that your medical information may be used or disclosed by this office. For clarification we have included some examples. Not every possible use or disclosure is specifically mentioned. However, all of the ways we are permitted to use and disclose your medical information will fit into one of these general categories:

  1. Treatment. We will use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians and other office personnel who are involved in providing you medical treatment.
  2. Payment. We may use and disclose medical information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received here so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
  3. Health Care Operations. We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run our office and make sure that all our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may remove information that identifies you from your medical record so that it may be used to study health care and health care delivery without learning the identity of the specific patients.
  4. Appointment Reminders. Our practice may contact you and remind you of an appointment either by postcard or by telephone.
  5. Treatment Options. Our practice may use and disclose your medical information to inform you of potential treatment options or alternatives.
  6. Disclosures Required By Law. Our practice will use and disclose your medical information when we are required to do so by federal, state or local law. For example, disclosures may be required by Workers’ Compensation statutes and various public health statutes in connection with required reporting of certain diseases, child abuse and neglect, domestic violence, etc.
  7. Research. Under certain circumstances, we may disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition.
  8. To Avert a Serious Threat to Health and Safety. We may use and disclose medical information about you when necessary 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 to someone able to help prevent the threat.
  9. Health Oversight Activities. We may disclose medical information to a governmental or other oversight agency for activities authorized by law. For example, disclosures of your medical information may be made in connection with audits, investigations, inspections, and licensure renewals, etc.
  10. Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may use your medical information to defend the practice or to respond to a court order.
  11. Law enforcement. We may release medical information about you if required by law when asked to do so by a law enforcement official.
D. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding the medical information that we maintain about you:

  1. Confidential Communications. You have the right to request that we communicate with you only in a certain manner. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to (see ** below) Our practice will accommodate all reasonable requests. You do not need to give a reason for your request.
  2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your medical information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your medical information, you must make your request in writing to (see ** below). Your request must describe in a clear and concise fashion:
    1. the information you wish restricted;
    2. whether you are requesting to limit our practice’s use, disclosure or both; and
    3. to whom you want the limits to apply.
  3. Inspection and Copies. You have the right to inspect and obtain a copy of your medical information. You must submit your request in writing to (see ** below). Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request.
  4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by our office. To request an amendment, your request must be made in writing and submitted to (see ** below). You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request and the reason supporting your request in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the medical information kept by this office; (c) not part of the medical information which you would be permitted to inspect and copy; or (d) not created by our practice.
  5. Accounting of Disclosures. You have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your medical information for non-treatment, non-payment or non-operations purposes. In order to obtain an accounting of disclosures, you must submit your request in writing to (see ** below). All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before 2007.
  6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact (see ** below).
  7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact (see ** below). All complaints must be submitted in writing. You will not be penalized for filing a complaint.
  8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization.

** If you have any questions regarding this notice or requests to make in regard to it, please write/contact Robert M. Soderstrom, M.D., Attn: Audrey, G-5131 W. Bristol Rd., Flint, MI 48507, (810) 733-2090.