KENT RADIOLOGY, P.C.
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.

THIS NOTICE IS EFFECTIVE AS OF APRIL 14, 2003

It is our policy and commitment to you to determine the appropriate uses of your Protected Health Information (“PHI”, for short) and to provide you with a notice of our legal duties and privacy practices with respect to PHI. What is PHI? It is information about you, including basic demographic information, that may identify you and that relates to your past, present or future health condition and related health care services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI about you to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law, commonly known as HIPAA.

We are required to provide you with this Notice about our privacy practices and we will ask you to sign an acknowledgment that states that we have complied. It is not stating that you agree, but that we complied with the regulations in providing it to you

We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide a revised Notice to you.

The Notice also describes your rights as a patient.

HOW WE MAY USE AND DISCLOSE YOUR PHI:
We may use and disclose health information for treatment, payment or health care operations and for some legal reasons without your written authorization. But, there may be times when we need your specific authorization. For example: releasing information to your attorney, or a personal representative.

Below we describe the different categories of our uses and disclosures and give you some examples of each category.

We will use PHI for treatment: We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you with health care services or are involved in your care. For example: If your physician sends you to us for a chest x-ray we will send a transcribed report to his office with the results.

We will use PHI for payment. Example: We may use and disclose your PHI in order to bill and collect payment for the services that we rendered to you. For example: we may provide information to our business associates, such as billing company, claims processing companies, and your health plan in order to get paid for the services provided. We may contact your insurer to determine why they have not paid for your services. The information on or accompanying the bill may include information that identifies you.

We will use PHI for Other Health Care Providers: We may disclose PHI about you for treatment with other health care providers. We may also disclose PHI about you to another health care provider for the health care operation’s activities (quality assessments, competence, and performance reviews as well as others) of that health care provider providing they too have a relationship with you. We may also disclose
PHI about you to such a health care provider for the purpose of health care fraud and abuse detection or compliance.

CERTAIN USES THAT DO NOT REQUIRE YOUR AUTHORIZATION.
We may use or disclose PHI for the following purposes:

Business Associates: There are some services provided by us through contracts with business associates. Examples: We currently contract with a Shredding Services to destroy paper documents that are no longer needed and may contain PHI. We currently contract with a company to perform the billing operation for our practice. We currently contract with collection agencies to collect past due accounts. Our Business Associates have signed agreements with us to protect and safeguard your PHI.

Appointment Reminders and Personal communications: We may contact you to provide appointment reminders or information about treatment or other health-related benefits and services that may be of interest to you.

Worker’s Compensation: We may disclose PHI about you to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Auto Insurance: We will request your authorization to release medical records, but we can bill your auto insurance for payment for services rendered.

Public health: As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Law enforcement: We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena.

As required by law: We must disclose PHI about you when required to do so by law.

Health oversight activities: We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Food and Drug Administration (FDA): We may disclose to the FDA or its agents PHI relative to mammography outcomes.

Judicial and administrative proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI.

We are permitted to use or disclose PHI about you for the following purposes:

Coroners, medical examiners, and funeral directors: We may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Correctional institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents, PHI necessary for your health and the health and safety of others.

To avert a serious threat to health or safety: We may use and disclose PHI 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.

Military and veterans: If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.

National security and intelligence activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Victims of abuse, neglect, or domestic violence: We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only discuss this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or the law enforcement or public official that is to receive the report represents that is necessary and will not be used against you.

Other Uses and Disclosures of PHI
Except for uses and disclosures stated above, we will obtain your written authorization before using or disclosing PHI about you. You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization.

Uses and Disclosures Permitted but Allows You to Restrict.
Communication with individuals involved in your care or payment for your care: We may disclose PHI to a family member, other relative, close personal friend or any person that you identify, relevant to the individuals involvement in your care or payment related to your care. You may restrict us from disclosing information by requesting this in writing to our Privacy Officer (see below).

Your Health Information Rights

Authorization forms are available at each of our office locations. If you have questions or would like additional information, you may contact our Privacy Office at 1-616-364-5228 x1. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Privacy Officer
Kent Radiology P.C.
P.O. Box 186
Grand Rapids, MI 49501-0186

YOUR RIGHTS AS A PATIENT REGARDING PHI:

Request a restriction on certain uses and disclosures of PHI. You have the right to request that we limit how we use or disclosure of PHI about you by sending a written request to our Privacy Officer (address listed above). You need to provide detailed information for us to process your request. We will consider your request but are not legally required to honor the request. We will provide an explanation or any limitations in writing to you and abide by them except in emergency situations, if applicable. You may not limit the uses and disclosures permitted or required by law.

Inspect and obtain a copy of PHI. You have the right to access and obtain a copy of PHI about you contained in a designated record set for as long as we maintain the PHI. The “designated record set” usually will include treatment and/or billing records. To inspect or copy PHI about you, you must send a written request to our Privacy Officer (address listed above). The requests must provide adequate information for us to process your request. We may charge you a fee for the costs of copying, mailing, or other supplies that are necessary to grant your request. If you request copies of your films, you will be charged at our current fee schedule. The fee schedule is available at any of our office locations.

We will respond within 30 days after receiving your written request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about yourself, you may request that the denial be reviewed. If we don’t have your requested PHI but we know who does, we will inform you how to get it.

Request an amendment of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to the Privacy Officer (address listed above). You must include an explanation that supports your request. In certain cases, we may deny your request for amendment. We will respond within 60 days of the request. We may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision.

Receive an accounting of disclosures of PHI. After April 14, 2003, you have the right to receive an accounting of the disclosures we have made of PHI about you for most purposes other than treatment, payment, or health care operations. The accounting will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The list will not include uses and disclosures for national security purposes or other restrictions dictated by law.

To request an accounting, you must submit your request in writing to our Privacy Officer (address listed above). Your request must specify the time period, but may not be longer than six years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings within the same period of time. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

Request communications of PHI by alternative means or at alternative locations. For instance, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of PHI about you, you must submit your request in writing to our Privacy Officer (address listed above). Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests as long as we can provide it in the format you requested.

We are required to provide you with this Notice about our privacy practices and we will ask you to sign an acknowledgment that states that we have complied. It is not stating that you agree, but that we complied with the regulations in providing it to you

You may request a copy of the Notice at any time.

We welcome your inquiry or if you feel that an event in any way compromises your privacy please feel free to contact us.
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