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 heath 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. The 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 access 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 using our professional judgment and experience it is in your best interest.
• We my contact you to provide appointment reminders via phone or mail. We may leave messages on your answering machine for these reminders.
• We may also contact you by phone or mail to share results of medical tests that were performed or requested by your doctor. We will not leave your results on an answering machine, but we will leave you a message to call us back. If you prefer not to receive this information by phone or mail, please inform us.
• 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 our 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 of 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 heath 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 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 to 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 an appointment.

You also have the 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 alternative means or at an alternative 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 alternative means or at an alternate location, you may file a written complaint to the U.S. Department of Health and Human Services and we will provide you with the address upon request.
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.

Contact Information: Privacy Officer
Address: 970 Parchment Drive, SE Suite 203, Grand Rapids MI 49546
Phone: (616) 949-4840
Fax: (616) 949-3531