Welcme T Advanas Ft & Ankle Specialists We want t thank yu fr trusting Advanas Ft & Ankle Specialists with yur healthcare needs. At Advanas Ft & Ankle Specialists we pride urselves n being a pleasant envirnment with caring staff whse gal is t prvide the latest in treatment ptins fr every ft and ankle prblem. We understand yu have many ptins when it cmes t yur ft and ankle care and we are hnred that yu have chsen us. Again, let me thank yu fr yur cnfidence in us. Sincerely, Dr. Trevr Neal CEO Advanas Ft & Ankle Specialists
Getting T Knw Our Physicians DR. TREVOR NEAL: In 1989, Dr. Trevr Neal purchased a part time pdiatry practice with the intent and visin f prviding quality pdiatric care fr patients in Sturgis and the surrunding area, and has spread t becme 6 practices. During the mre than 20 years f practice, many state f the art treatment mdalities have been implemented. Here at Advanas/ Sturgis SurgiCare we feel that we ffer the very best that is available in ft and ankle care. Dr. Trevr Neal received his Bachelr f Science degree frm Western Illinis University in 1979, and his Dctr f Pdiatric Medicine degree in 1983 frm the Schl Cllege f Pdiatric Medicine, a divisin f the Fitch Cllege f Medicine. Dr. Neal then cmpleted a surgical residency in 1986 and became bard certified in ft and ankle surgery by the American Bard f Pdiatric Surgery in 1990. In 1994, he became a member f the fellw f American Clleges f Ft and Ankle Surgens. Dr. Neal is als a member f the American Pdiatric Medical Assciatin and Michigan Pdiatric Medical Assciatin. DR. CHRISTOPHER BUSSEMA: Dr. Bussema has prudly practiced pdiatric medicine in Michigan and Indiana and is dedicated t prviding advanced ft and ankle care. Grwing up in Kalamaz, he acquired his Bachelr f Science at Western Michigan University. Dr. Bussema received his medical degree frm Ohi Cllege f Pdiatric Medicine in Cleveland Ohi and cmpleted a three year surgical residency in Yungstwn, Ohi. Dr. Bussema is an assciate member f American Cllege f Ft and Ankle Surgens, American Pdiatric Medical Assciatin, and Michigan Pdiatric Medical Assciatin. DR. KATHLEEN BICKLE: Dr. Kathleen Bickle is a Michigan native as she was brn and raised in Suthwest Michigan. She earned her Bachelr s f Arts at Kalamaz Cllege befre mving t Chicag t cmplete her dctrate at the Schll Cllege f Pdiatric Medicine, a divisin f Rsalind Franklin University. Dr. Bickle has since returned t Suthwest Michigan and has been with Advanas since 2010. Dr. Bickle is a member f the Michigan Pdiatric Medical Assciatin. DR. ROBERT MONFORE: Dr. Mnfre graduated frm Schll Cllege f Pdiatric Medicine, a divisin f Rsalind Franklin University in 2010. He did his residency at McLaren Oakland Hspital in Pntiac, MI. Dr. Mnfre is a member f the APMA, ACFAS, and ABPM. Dr. Mnfre s prfessinal interests include bimechanics, practice management, freft surgery, and DME. Outside f the ffice he enjys being utdrs, spending time with his dgs, running, scuba diving, cars and hckey. Dr. Harshini Avula: Dr. Avula cmpleted her medical educatin at the Ohi Cllege f Pdiatric Medicine in Independence, Ohi, fllwed by successfully cmpleting her surgical residency training at Sisters f Charity Hspital, Buffal NY with specialty training in ft and ankle recnstructin. In additin, Dr. Avula ffers cmprehensive care prviding cnservative and surgical ptins and treats a full range f ft and ankle pathlgies and injuries. If yu are having a surgical prcedure at ur facility, the Certified Registered Nurse Anesthetist will prvide yu with the infrmatin regarding their credentials upn request. Public: Master File Overall: Clerical Patient Rights and Respnsibilities 7-27-2015
Patient Demgraphics Advanas Ft & Ankle Specialists/Sturgis Surgi-Care Patient Infrmatin Name (First) (Middle Initial) (Last) Birthdate Marital Status: Single/Married/Divrced/Widwed Sex: Female/Male Race: White/Black r African American/ Hispanic Ethnicity: Hispanic r Latin/Other Language: English/Spanish/Other Scial Security #: Hme Phne # Cell Phne # Email Address: Occasinally we Mail, Email, r Text patients with special infrmatin, can we cntact yu in this manner? Yes/N Respnsible Party Please Fill Out The Infrmatin Belw: Emplyer Occupatin Emplyer Address City State Zip Cde Wrk Phne # Full Name: Date f Birth: S.S. # Hw did yu hear abut us? We wuld like t thank them! Name: Address: City/State: Zip: Wh is yur Primary Care Physician? Name: Date f last visit? Phne # Physicians Address/Lcatin Pharmacy Name: Lcatin: FOOT HEALTH INFORMATION What is yur current ft/ankle cnditin? When did it begin? Have yu seen anther dctr fr this cnditin? Hw have yu treated this cnditin s far? Whm? Signature f Patient r Guardian: Date: OFFICE USE: Entered By: Date: Public: Master File - Overall: Clerical - Welcme T Our Office
Ntificatins I hereby give the physicians at Advanas Ft & Ankle Specialists/Sturgis SurgiCare permissin t examine and treat my feet. I als authrize the release f medical r ther infrmatin necessary t prcess any insurance claim, and authrize payment f medical benefits t Advanas Ft & Ankle Specialists/Sturgis SurgiCare. I certify that the infrmatin given t the staff at Advanas Ft & Ankle Specialists is true and crrect t the best f my knwledge and will ntify Advanas Ft & Ankle Specialists/Sturgis SurgiCare. if any f this infrmatin changes. Please Initial In Bx PATIENT RIGHTS AND RESPONSIBILITIES: I have been infrmed f my patient rights and respnsibilities. ADVANCE DIRECTIVES: I have been infrmed f my rights t frmulate an Advance Directive and understand that I am nt required t have an Advance Directive in rder t receive medical treatment in this health care facility. I understand that it is the plicy f this surgery center t resuscitate all patients that require resuscitatin in rder t maintain their vital functins. I understand that in the case f a medical emergency that I may be transferred t the lcal hspital. I HAVE frmulated an Advance Directive. If yu have initialed that yu have an Advanced Directive, yu must be aware that we d nt hnr them, we will d everything in ur pwer t save yu as lng as yu are in the ffice. FINANCIAL POLICY: I have read, understd and agree with all three pages f the financial plicy. I als understand that I may receive a cpy upn my request. Cnsent t release: I authrize my physician at Advanas Ft & Ankle Specialists t btain any utside infrmatin regarding my health r prescriptin histry frm external surces. DISCLOSURE OF OWNERSHIP: A crpratin frmed by Trevr Neal, D.P.M. wns Advanas Ft & Ankle Specialists and Sturgis SurgiCare. He has becme an wner as a result f his cmmitment t quality healthcare and t prvide better services t his patient. Please be advised f the fllwing: The facility may have a financial relatinship with yur physician as indicated abve. A schedule f typical fees fr services prvided by the facility may be available at yur request. Yu may have the right t chse where t receive services including an entity in which yur physician may have a financial relatinship. YOUR CONFIDENTIAL COMMUNICATIONS Persns whm we can cntact regarding yur treatment, care, appintments, r financial arrangements. Emergency Cntact: Phne#: Phne # we can leave a detailed message n: Spuse (Name): Children (Name): Care Giver (Name): Pwer f Attrney (Name): Lawyer (Name): Institutins (Name): Other(Name(s)): If n ne is listed in this sectin we will nly be able t speak t yu regarding yur persnal health infrmatin. I HAVE RECEIVED A COPY OF ADVANAS FOOT & ANKLE SPECIALISTS/STURGS SURGICARE/TREVOR NEAL D.P.M. NOTICE OF PRIVACY PRACTICES. Signature: Date: Public: Master File Overall: Clerical Ntificatin Entered By: Date:
PATIENT RIGHTS AND RESPONSIBLITIES In recgnitin f ur respnsibility in rendering patient care, these rights and respnsibilities are affirmed in the plicies and prcedures f Advanas/ Sturgis SurgiCare The patient has the right t T be treated with curtesy and respect, with appreciatin f his r her individual dignity and with prtectin f his r her need f privacy T an envirnment that is safe and secure fr self and prperty. T cnfidentiality f infrmatin gathered during treatment T prmpt and reasnable respnse t questins and requests. T knw wh is prviding and is respnsible fr his r her care. T knw what patient supprt service are available, including whether an interpreter is available if he r she des nt speak English T knw what rules and regulatins apply t his r her cnduct. T be given, upn request, full infrmatin and necessary cunseling n the availability f knwn financial resurces fr his r her care. T be given, upn request and in advance f treatment, whether the health care prvider r health care facility accepts the Advance Directives. T receive, upn request, prir t treatment, a reasnable estimate f charges fr medical care. T receive a cpy f reasnably clear and understandable, itemized bill and, upn request, t have charges explained. T receive impartial access t medical treatment r accmmdatins, regardless f race, natinal rigin, religin, physical handicap, r surce f payment. T receive treatment fr any emergency medical cnditin that will deterirate frm failure t prvide treatment. T knw if medical treatment is fr purpses f experimental/research and t give his r her cnsent r refusal t participate in such experimental research. T express grievances regarding any vilatins f his r her rights, thrugh the grievance prcedure f health care prvider which served him r her. T participate in all aspects f health care decisins, unless cntraindicated by cncerns fr their health. T apprpriate assessment and management f pain Public: Master File Overall: Clerical Patient Rights and Respnsibilities 7-27-2015
The patient is respnsible Fr prviding t the health care prvider, t the best f his r her knwledge, accurate and cmplete infrmatin abut present cmplaints, past illnesses, hspitalizatins, medicatins, and ther matters relating t his r her health. Fr reprting unexpected changes in his r her cnditin t the health care prvider. Fr reprting t the healthcare prvider whether he r she cmprehends a cntemplated curse f actin and what is expected f him r her. Fr fllwing the treatment plan recmmended by the health care prvider. Fr keeping appintments and when he r she is unable t d s fr any reasn, fr ntifying the Facility Fr his r her actins if he r she refuses treatment r des nt fllw the health care prviders instructins. Fr assuring that the financial bligatins f his r her health care fulfilled as prmptly as pssible. Fr fllwing Facility rules and regulatins affecting patient care and cnduct. Fr cnsideratin and respect f the Facility staff and prperty. Fr asking what t expect regarding pain and pain management. If yu have any cncerns r cmplaints regarding yur care, treatment, r services, please cntact Paula Hllister, Directr f Operatins at (269)651-2320. Public: Master File Overall: Clerical Patient Rights and Respnsibilities 7-27-2015
Financial Plicy Thank yu fr chsing us as yur ft and ankle specialists. We share yur cncern regarding the rising cst f healthcare. Because f this, we have established financial plicies which are necessary t help hld dwn the verall cst f yur care. We are cmmitted t yur treatment being successful. Please understand that payment f yur bill is cnsidered part f yur treatment. All C-pays and deductibles are due at the time f service unless prir arrangements have been made. We accept cash, check, mney rder, Visa, MasterCard, American Express, Discver, Paypal and Care Credit. Due t regulatins and changes in the healthcare industry, we are required t secure payment. This can be achieved by prviding us with current prf f cverage, pstdating a check, cash r placing a credit card n file with us. Our Crprate Cllectins Officer will help determine hw is best t prceed with yur balance. Yu may be asked t sign a prmissry nte shuld yur balance be ver $100.00. Our Crprate Cllectins Officer will als help yu determine if yur case wuld qualify fr financial hardship shuld yu run int difficulties. If this is the case, please cntact ur Crprate Cllectins Officer immediately. The sner arrangements are made the less likely additinal charges will ccur. Self Pay: A minimum depsit f $200.00 r the actual charge, whichever is less, is due at the time f service. Any subsequent visit charges will be due at time f service. If yu cannt pay in full, yu will need t set up and adhere t a payment plan with ur Crprate Cllectins Officer. Wrkers Cmpensatin: If yu are here as a result f a wrk related injury, we are required t have a letter r statement authrizing yur treatment frm yur emplyer r Wrkers Cmpensatin carrier. The letter shuld include the claim number, address, adjuster s name and phne number. Yur emplyer s human resurce ffice shuld be able t assist yu with btaining this infrmatin. Withut this infrmatin, yu will nly be seen n a self-pay basis until arrangements and the necessary paperwrk has been cmpleted. Insurance: Due t the extremely large number f insurance cmpanies, it is impssible fr us t be acquainted with each individual plicy s guidelines. While we will be f any assistance pssible, yur plicy is yur respnsibility t be familiar with. We will gladly set an appintment t talk with yu and yur insurance agency tgether t help ensure and secure payment frm yur insurance cmpany. / / / / / / Public: Master File Overall: Clerical Financial Plicy 01/28/2016
The fllwing are cmmn terms assciated with insurance: EOB Explanatin f Benefits: This is a statement frm yur insurance cmpany f what they have allwed, paid r denied. Deductible: The amunt yu are respnsible fr each year prir t any payment being made frm yur insurance cmpany C-Pay: A set fee yu are legally respnsible fr at each ffice visit r prcedure. C-Insurance: A percentage f the services rendered nt paid by yur insurance cmpany R&C Reasnable and Custmary: The amunt yur insurance cmpany determined they will pay fr any specific prcedure. Yur insurance plicy is a cntract between yu and yur insurance cmpany. In rder t help yu with yur insurance, we require a cpy f yur insurance card. Therefre, please have yur insurance card every time yu visit the ffice. If current infrmatin is unable t be btained at the time f service, it will be yur respnsibility t pay yur balance in full at that time f service. As a curtesy, we will file yur insurance claim fr yu. Yu must assign the benefits t the dctr. In ther wrds, yu agree t have yur insurance cmpany pay the dctr(s), Advanas Ft and Ankle Specialists, Sturgis SurgiCare, Trevr Neal, D.P.M., Christpher Bussema, D.P.M., Kathleen Bickle, D.P.M., and Rbert Mnfre, D.P.M. r Harshini Avula D.P.M. directly. Due t the ever changing insurance plicies and their names, we will attempt t submit claims n all plicies with the exceptin f Medicaid, as it is nt a plicy we are in netwrk with at this time. Any patient wh chses us fr their care, and is insured thrugh Medicaid, will be required t pay self-pay rates and submit their wn claims. We will prvide any infrmatin we have available t assist yu. Yur insurance is yur respnsibility and as such it is yur respnsibility t cntact yur insurance t make sure we are in netwrk with them. Any assistance we can prvide please let us knw. It is mst cmmn fr the insurance cmpanies t make the fllwing statement at the beginning f any call. This call may be mnitred and recrded fr security purpses. Please remember any statements made regarding cverage is nt a guarantee f payment. While we are used t this statement and mst times the insurance still pays, we feel yu shuld be made aware f hw they state things s we cannt ever be 100% sure they will make the payments. Nrmally, yu will nly receive a bill frm us nce yur insurance cmpany has paid. We send yur insurance claim within 30 days f services and mst generally within 7 days f service. Hwever, if yur insurance cmpany des nt pay, r we have nt heard frm them within 90 days, yu will receive a statement frm us as we will assume yur insurance cmpany has made payment t yu directly. Please remember that it is yur respnsibility t prmptly answer any requests fr infrmatin frm yur insurance cmpany which might hld up prcessing f yur claim. Mst insurance cmpanies will send yu an EOB within 45 days. If yu have nt heard frm them we encurage yu t cntact them t determine the status f yur claim. All health plans are nt the same and d nt cver the same services. In the event yur health plan determines a service t be nt cvered r yu d nt have an authrizatin, yu will be / / / / / / Public: Master File Overall: Clerical Financial Plicy 01/28/2016
respnsible fr the cmplete charge. We will attempt t verify benefits fr sme specialized services; hwever, yu remain respnsible fr charges f any services rendered. Patients are encuraged t cntact their plans fr clarificatin f benefits prir t services rendered. Yu must infrm the ffice f all insurance changes and authrizatin referral requirements. In the event the ffice is nt infrmed, yu will be respnsible fr any charges denied. If yu have tw medical insurance plans, it is yur respnsibility t infrm us which plan is yur primary (first), and which is yur secndary (secnd). Yu must infrm us if ne r bth insurance plans change r are n lnger in effect. We will gladly bill the secndary insurance fr yu as lng as the balance remaining after the primary insurance has paid is greater than $100.00. If the balance remaining after the primary insurance has paid is belw $100.00 yu will be respnsible fr the payment and the filing f the claim with yur secndary insurance if yu wish. Als please nte that all billing is dne thrugh ur billing ffice lcated in Sturgis, Michigan. Yu may receive ntice frm us r yur insurance cmpany with Advanas Ft and Ankle Specialist infrmatin. Medicare: We accept Medicare assignment. Yu are respnsible fr yur deductible, and c-insurance, any service deemed Medically Unnecessary r nn-cvered services r supplies, and the difference between the apprved charge and the amunt Medicare pays. If yu have supplemental insurance, we will submit the claim fr yu. Hwever, nt all supplemental insurances cver all services s any remaining balance will be billed t yu. Fees and Payments: In rder t cntrl csts, payment fr all c-pays and deductibles is expected at the time services are perfrmed. If yu are unable t d s, please discuss yur situatin with ur Crprate Cllectins Officer s special arrangements can be made. If arrangements have nt been made and yu are unable t pay yur c-pay, a $25.00 billing fee will apply. We will make every effrt t accmmdate unusual circumstances that make yur financial bligatins difficult t fulfill. If yu are suddenly ging thrugh financial hardship, please cntact ur Crprate Cllectins Officer t discuss yur situatin. The fees fr evaluatin and treatment vary depending upn the cmplexity f yur cnditin and the treatment required. There are fees fr requesting medical recrds. The fee depends n yur file size and the cmplexity f yur care. Fees can range frm 25.00-250.00 s please determine the amunt yu wish t spend prir t btaining the recrds. There is a restcking fee fr prducts that are eligible t be returned. This fee will be the minimum f 65.00 fr prducts r durable medical equipment returned t ur facility in great cnditin. Past due accunts are subject t cllectin prceedings. All fees including, but nt limited t cllectin fees, attrney fees, and curt fees shall becme yur respnsibility in additin t the balance due n yur accunt at this ffice. / / / / / / Public: Master File Overall: Clerical Financial Plicy 01/28/2016
There are certain prcedures that require prepayment. Yu will be infrmed in advance if yur prcedure is ne f thse. In that event, payment will be due ne week prir t the prcedure. As a curtesy t ur patients, yu are have the ptin t place yur credit card n file with us. Any balance remaining after yur insurance has paid will be placed n yur credit card. Please ask the receptinist fr a cpy f ur payment agreement if yu wuld like this ptin. There is a $50.00 service fee fr all returned checks. Yu insurance cmpany will nt cver this fee. In the event f a returned check yu may als be placed n a Cash Only basis. If yu have any questins regarding yur treatment, yur accunt r ur ffice plicies, please phne during business hurs. Our main cncern is taking care f yu and yur lved nes. Please d nt hesitate t talk with ur Crprate Cllectins Officer r Directr f Operatins shuld yu find yurself in a situatin yu feel needs discussed. Thank yu fr yur cntinued supprt. / / / / / / Public: Master File Overall: Clerical Financial Plicy 01/28/2016
Ntice Of Privacy Practices Effective Date: 1-1-2014 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 yu have any questins abut this ntice, please cntact Paula Hllister at 269.651.2320. OUR OBLIGATIONS: We are required by law t: Maintain the privacy f prtected health infrmatin Give yu this ntice f ur legal duties and privacy practices regarding health infrmatin abut yu Fllw the terms f ur ntice that is currently in effect HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION: The fllwing describes the ways we may use and disclse health infrmatin that identifies yu ( Health Infrmatin ). Except fr the purpses described belw, we will use and disclse Health Infrmatin nly with yur written permissin. Yu may revke such permissin at any time by writing t ur practice Privacy Officer. Fr Treatment. We may use and disclse Health Infrmatin fr yur treatment and t prvide yu with treatment-related health care services. Fr example, we may disclse Health Infrmatin t dctrs, nurses, technicians, r ther persnnel, including peple utside ur ffice, wh are invlved in yur medical care and need the infrmatin t prvide yu with medical care. Fr Payment. We may use and disclse Health Infrmatin s that we r thers may bill and receive payment frm yu, an insurance cmpany r a third party fr the treatment and services yu received. Fr example, we may give yur health plan infrmatin abut yu s that they will pay fr yur treatment. Public: Master File Overall: Clerical Ntice f Privacy Practices
Fr Health Care Operatins. We may use and disclse Health Infrmatin fr health care peratins purpses. These uses and disclsures are necessary t make sure that all f ur patients receive quality care and t perate and manage ur ffice. Fr example, we may use and disclse infrmatin t make sure the bstetrical r gyneclgical care yu receive is f the highest quality. We als may share infrmatin with ther entities that have a relatinship with yu (fr example, yur health plan) fr their health care peratin activities. Appintment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclse Health Infrmatin t cntact yu t remind yu that yu have an appintment with us. We als may use and disclse Health Infrmatin t tell yu abut treatment alternatives r health-related benefits and services that may be f interest t yu. Individuals Invlved in Yur Care r Payment fr Yur Care. When apprpriate, we may share Health Infrmatin with a persn wh is invlved in yur medical care r payment fr yur care, such as yur family r a clse friend. We als may ntify yur family abut yur lcatin r general cnditin r disclse such infrmatin t an entity assisting in a disaster relief effrt. Research. Under certain circumstances, we may use and disclse Health Infrmatin fr research. Fr example, a research prject may invlve cmparing the health f patients wh received ne treatment t thse wh received anther, fr the same cnditin. Befre we use r disclse Health Infrmatin fr research, the prject will g thrugh a special apprval prcess. Even withut special apprval, we may permit researchers t lk at recrds t help them identify patients wh may be included in their research prject r fr ther similar purpses, as lng as they d nt remve r take a cpy f any Health Infrmatin. SPECIAL SITUATIONS: As Required by Law. We will disclse Health Infrmatin when required t d s by internatinal, federal, state r lcal law. T Avert a Serius Threat t Health r Safety. We may use and disclse Health Infrmatin when necessary t prevent a serius threat t yur health and safety r the health and safety f the public r anther persn. Disclsures, hwever, will be made nly t smene wh may be able t help prevent the threat. Business Assciates. We may disclse Health Infrmatin t ur business assciates that perfrm functins n ur behalf r prvide us with services if the infrmatin is necessary fr such functins r services. Fr example, we may use anther cmpany t perfrm billing services n ur behalf. All f ur business assciates are bligated t prtect the privacy f yur infrmatin and are nt allwed t use r disclse any infrmatin ther than as specified in ur cntract. Organ and Tissue Dnatin. If yu are an rgan dnr, we may use r release Health Infrmatin t rganizatins that handle rgan prcurement r ther entities engaged in prcurement, banking r transprtatin f rgans, eyes r tissues t facilitate rgan, eye r tissue dnatin and transplantatin. Public: Master File Overall: Clerical Ntice f Privacy Practices
Military and Veterans. If yu are a member f the armed frces, we may release Health Infrmatin as required by military cmmand authrities. We als may release Health Infrmatin t the apprpriate freign military authrity if yu are a member f a freign military. Wrkers Cmpensatin. We may release Health Infrmatin fr wrkers cmpensatin r similar prgrams. These prgrams prvide benefits fr wrk-related injuries r illness. Public Health Risks. We may disclse Health Infrmatin fr public health activities. These activities generally include disclsures t prevent r cntrl disease, injury r disability; reprt births and deaths; reprt child abuse r neglect; reprt reactins t medicatins r prblems with prducts; ntify peple f recalls f prducts they may be using; a persn wh may have been expsed t a disease r may be at risk fr cntracting r spreading a disease r cnditin; and the apprpriate gvernment authrity if we believe a patient has been the victim f abuse, neglect r dmestic vilence. We will nly make this disclsure if yu agree r when required r authrized by law. Health Oversight Activities. We may disclse Health Infrmatin t a health versight agency fr activities authrized by law. These versight activities include, fr example, audits, investigatins, inspectins, and licensure. These activities are necessary fr the gvernment t mnitr the health care system, gvernment prgrams, and cmpliance with civil rights laws. Data Breach Ntificatin Purpses. We may use r disclse yur Prtected Health Infrmatin t prvide legally required ntices f unauthrized access t r disclsure f yur health infrmatin. Lawsuits and Disputes. If yu are invlved in a lawsuit r a dispute, we may disclse Health Infrmatin in respnse t a curt r administrative rder. We als may disclse Health Infrmatin in respnse t a subpena, discvery request, r ther lawful prcess by smene else invlved in the dispute, but nly if effrts have been made t tell yu abut the request r t btain an rder prtecting the infrmatin requested. Law Enfrcement. We may release Health Infrmatin if asked by a law enfrcement fficial if the infrmatin is: (1) in respnse t a curt rder, subpena, warrant, summns r similar prcess; (2) limited infrmatin t identify r lcate a suspect, fugitive, material witness, r missing persn; (3) abut the victim f a crime even if, under certain very limited circumstances, we are unable t btain the persn s agreement; (4) abut a death we believe may be the result f criminal cnduct; (5) abut criminal cnduct n ur premises; and (6) in an emergency t reprt a crime, the lcatin f the crime r victims, r the identity, descriptin r lcatin f the persn wh cmmitted the crime. Crners, Medical Examiners and Funeral Directrs. We may release Health Infrmatin t a crner r medical examiner. This may be necessary, fr example, t identify a deceased persn r determine the cause f death. We als may release Health Infrmatin t funeral directrs as necessary fr their duties. Natinal Security and Intelligence Activities. We may release Health Infrmatin t authrized federal fficials fr intelligence, cunter-intelligence, and ther natinal security activities authrized by law. Public: Master File Overall: Clerical Ntice f Privacy Practices
Prtective Services fr the President and Others. We may disclse Health Infrmatin t authrized federal fficials s they may prvide prtectin t the President, ther authrized persns r freign heads f state r t cnduct special investigatins. Inmates r Individuals in Custdy. If yu are an inmate f a crrectinal institutin r under the custdy f a law enfrcement fficial, we may release Health Infrmatin t the crrectinal institutin r law enfrcement fficial. This release wuld be if necessary: (1) fr the institutin t prvide yu with health care; (2) t prtect yur health and safety r the health and safety f thers; r (3) the safety and security f the crrectinal institutin. USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT Individuals Invlved in Yur Care r Payment fr Yur Care. Unless yu bject, we may disclse t a member f yur family, a relative, a clse friend r any ther persn yu identify, yur Prtected Health Infrmatin that directly relates t that persn s invlvement in yur health care., If yu are unable t agree r bject t such a disclsure, we may disclse such infrmatin as necessary if we determine that it is in yur best interest based n ur prfessinal judgment. Disaster Relief. We may disclse yur Prtected Health Infrmatin t disaster relief rganizatins that seek yur Prtected Health Infrmatin t crdinate yur care, r ntify family and friends f yur lcatin r cnditin in a disaster. We will prvide yu with an pprtunity t agree r bject t such a disclsure whenever we practically can d s. YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES The fllwing uses and disclsures f yur Prtected Health Infrmatin will be made nly with yur written authrizatin: 1. Uses and disclsures f Prtected Health Infrmatin fr marketing purpses; and 2. Disclsures that cnstitute a sale f yur Prtected Health Infrmatin Other uses and disclsures f Prtected Health Infrmatin nt cvered by this Ntice r the laws that apply t us will be made nly with yur written authrizatin. If yu d give us an authrizatin, yu may revke it at any time by submitting a written revcatin t ur Privacy Officer and we will n lnger disclse Prtected Health Infrmatin under the authrizatin. But disclsure that we made in reliance n yur authrizatin befre yu revked it will nt be affected by the revcatin. YOUR RIGHTS: Yu have the fllwing rights regarding Health Infrmatin we have abut yu: Right t Inspect and Cpy. Yu have a right t inspect and cpy Health Infrmatin that may be used t make decisins abut yur care r payment fr yur care. This includes medical and billing recrds, ther than psychtherapy ntes. T inspect and cpy this Health Infrmatin, yu must make yur request, in writing, t ur Medical Recrds Office. We have up t 30 days t make yur Prtected Health Infrmatin available t yu Public: Master File Overall: Clerical Ntice f Privacy Practices
and we may charge yu a reasnable fee fr the csts f cpying, mailing r ther supplies assciated with yur request. We may nt charge yu a fee if yu need the infrmatin fr a claim fr benefits under the Scial Security Act r any ther state f federal needs-based benefit prgram. We may deny yur request in certain limited circumstances. If we d deny yur request, yu have the right t have the denial reviewed by a licensed healthcare prfessinal wh was nt directly invlved in the denial f yur request, and we will cmply with the utcme f the review. Right t an Electrnic Cpy f Electrnic Medical Recrds. If yur Prtected Health Infrmatin is maintained in an electrnic frmat (knwn as an electrnic medical recrd r an electrnic health recrd), yu have the right t request that an electrnic cpy f yur recrd be given t yu r transmitted t anther individual r entity. We will make every effrt t prvide access t yur Prtected Health Infrmatin in the frm r frmat yu request, if it is readily prducible in such frm r frmat. If the Prtected Health Infrmatin is nt readily prducible in the frm r frmat yu request yur recrd will be prvided in either ur standard electrnic frmat r if yu d nt want this frm r frmat, a readable hard cpy frm. We may charge yu a reasnable, cst-based fee fr the labr assciated with transmitting the electrnic medical recrd. Right t Get Ntice f a Breach. Yu have the right t be ntified upn a breach f any f yur unsecured Prtected Health Infrmatin. Right t Amend. If yu feel that Health Infrmatin we have is incrrect r incmplete, yu may ask us t amend the infrmatin. Yu have the right t request an amendment fr as lng as the infrmatin is kept by r fr ur ffice. T request an amendment, yu must make yur request, in writing, t Paula Hllister, Facility Directr. Right t an Accunting f Disclsures. Yu have the right t request a list f certain disclsures we made f Health Infrmatin fr purpses ther than treatment, payment and health care peratins r fr which yu prvided written authrizatin. T request an accunting f disclsures, yu must make yur request, in writing, t Medical Recrds. Right t Request Restrictins. Yu have the right t request a restrictin r limitatin n the Health Infrmatin we use r disclse fr treatment, payment, r health care peratins. Yu als have the right t request a limit n the Health Infrmatin we disclse t smene invlved in yur care r the payment fr yur care, like a family member r friend. Fr example, yu culd ask that we nt share infrmatin abut a particular diagnsis r treatment with yur spuse. T request a restrictin, yu must make yur request, in writing, t Paula Hllister, Facility Directr. We are nt required t agree t yur request unless yu are asking us t restrict the use and disclsure f yur Prtected Health Infrmatin t a health plan fr payment r health care peratin purpses and such infrmatin yu wish t restrict pertains slely t a health care item r service fr which yu have paid us ut-f-pcket in full. If we agree, we will cmply with yur request unless the infrmatin is needed t prvide yu with emergency treatment. Out-f-Pcket-Payments. If yu paid ut-f-pcket (r in ther wrds, yu have requested that we nt bill yur health plan) in full fr a specific item r service, yu have the right t ask that yur Prtected Health Infrmatin with respect t that item r service nt be disclsed t a health plan fr purpses f payment r health care peratins, and we will hnr that request. Public: Master File Overall: Clerical Ntice f Privacy Practices
Right t Request Cnfidential Cmmunicatins. Yu have the right t request that we cmmunicate with yu abut medical matters in a certain way r at a certain lcatin. Fr example, yu can ask that we nly cntact yu by mail r at wrk. T request cnfidential cmmunicatins, yu must make yur request, in writing, t Paula Hllister, Facility Directr. Yur request must specify hw r where yu wish t be cntacted. We will accmmdate reasnable requests. Right t a Paper Cpy f This Ntice. Yu have the right t a paper cpy f this ntice. Yu may ask us t give yu a cpy f this ntice at any time. Even if yu have agreed t receive this ntice electrnically, yu are still entitled t a paper cpy f this ntice. T btain a paper cpy f this ntice, simply ask at the frnt desk r cntact Paula Hllister, Facility directr, r mail a request t 102 S. Lakeview Ave. Sturgis MI, 49091. CHANGES TO THIS NOTICE: We reserve the right t change this ntice and make the new ntice apply t Health Infrmatin we already have as well as any infrmatin we receive in the future. We will pst a cpy f ur current ntice at ur ffice. The ntice will cntain the effective date n the first page, in the tp right-hand crner. COMPLAINTS: If yu believe yur privacy rights have been vilated, yu may file a cmplaint with ur ffice r with the Secretary f the Department f Health and Human Services. T file a cmplaint with ur ffice, cntact Paula Hllister, Facility Directr, by mail at 102 S. Lakeview Ave. Sturgis, MI 49091. All cmplaints must be made in writing. Yu will nt be penalized fr filing a cmplaint. Fr mre infrmatin n HIPAA privacy requirements, HIPAA electrnic transactins and cde sets regulatins and the prpsed HIPAA security rules, please visit ACOG s web site, www.acg.rg, r call (202) 863-2584. Public: Master File Overall: Clerical Ntice f Privacy Practices