BIRMINGHAM MAPLE CLINIC

JOINT 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

Effective Date: September 20, 2013

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated or otherwise maintained by Birmingham Maple Clinic.

This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Maintain the privacy of your medical information that identifies you;
• 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.

WHO WILL FOLLOW THIS NOTICE

This Notice will cover Birmingham Maple Clinic and those health care  providers who, while not necessarily legally affiliated with us, may provide you with care or treatment at Birmingham Maple Clinic. Together, Birmingham Maple Clinic and these providers are part of the “Birmingham Maple Clinic Organized Health Care Arrangement” (referred to as an “OHCA”).  This Notice describes privacy practices of those participating in the Birmingham Maple Clinic OHCA.  This Notice covers:

•   Any health care professional authorized to enter information into any medical record established and maintained by Birmingham Maple Clinic.
•   All departments and units of Birmingham Maple Clinic.
•   All employees, staff, volunteers and other Birmingham Maple Clinic personnel.
•   The individual health care providers of Birmingham Maple Clinic.
•   Bradley S. Klein, D.O., P.L.C.
•   Jeffrey A. London, M.D., P.C.
•   Brooke Weingarden, D.O., M.P.H., P.L.L.C.

In addition, Birmingham Maple Clinic and the Birmingham Maple Clinic OHCA may share your medical information with each other for treatment, payment or health care operations purposes described in this Notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

The following categories describe different ways that we use and disclose your health information. For each category we explain what we mean and give some examples. Our records contain information regarding your mental health or may contain information on substance abuse; those records may be subject to additional restrictions under state law, which we will comply with. Also, if you are a minor, certain specific information that relates to mental health, substance abuse, pregnancy or sexually transmitted diseases, may be protected by additional restrictions under state law, which we will comply with. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities might include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government benefit programs, and compliance with civil rights laws.

About Victims of Abuse. We may disclose your health information to notify the appropriate government authority if we believe an individual has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

As Required By Law. We will disclose your health information when required to do so by federal, state or local law or regulation.

Communications Regarding Our Services or Products. We may use and disclose your health information to make a communication to you to describe a health-related product or service of Birmingham Maple Clinic. In addition, we may use or disclose your health information to tell you about products or services related to your treatment, case management or care coordination, or alternative treatments, therapies, providers or settings of care for you. We may occasionally tell you about another company’s products or services, but will use or disclose your health information for such communications only if they occur in person with you. We may also use and disclose your health information to give you a promotional gift from us that is a minimal value.

Treatment Alternatives, Appointment Reminders and Health-Related Benefits. We may use and disclose your health information to tell you about or recommend possible treatment alternatives or health-related benefits or services that may be of interest to you. Additionally, we may use and disclose your health information to contact you by mail or phone to provide appointment reminders. If you do not wish us to contact you about treatment alternatives, health-related benefits or appointment reminders, you must notify us in writing, and state which of those activities you wish to be excluded from.

Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a family member or relative, personal representative, or any other person identified by you who is involved in your health care. We may also give information to someone who is involved with or helps pay for your care. We may also tell your family, friends, personal representative or other person responsible for your health care your condition and that you are at a hospital.

Business Associates.  We sometimes contact with third-party business associates for services.  For example, these business associates include billing services, medical transcriptionists, answering services, consultants, and attorneys.  We will disclose your medical information to our business associates to the extent necessary for them to perform the requested services.  Our business associates are required by law to protect your medical information just as we are required to do so.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written authorization. These may include, but are not limited to, the following: (i) most uses and disclosures of psychotherapy notes; (ii) uses and disclosures for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of health information. If you provide us with authorization to use or disclose your health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization.

You understand that we are unable to take back any disclosures we have already made under the authorization, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION 

You have the following rights regarding health information we maintain about you: operations; disclosures made pursuant to your authorization or made directly to you; disclosures made incident to a use or a disclosure otherwise permitted by law; disclosures made to create a limited data set; and disclosures made for national security or intelligence purposes and disclosures made to correctional institutions or to law enforcement officials.

To request this list of disclosures, you must submit your request in writing and submit it to the individual at the address identified at the end of this Notice. Your request must state a time period that may not be longer than six years prior to the date of the request. Your request should indicate in what form you want the list; for example, either paper or electronically. The first list you request within a twelve-month period will be free. For additional lists, during such twelve-month period, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

To obtain a paper copy of this Notice, contact us in writing and submit it to the individual at the address identified at the end of this Notice.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in a clear and prominent location to which you have access. The Notice is also available to you upon request. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, if we revise the Notice, you may request a copy of the revised Notice then in effect.

COMPLAINTS

In the event that there is a breach of your unsecured health information – meaning an unauthorized disclosure where your health information has not been made unusable, unreadable, or indecipherable – we are required to notify you of such breach.

Upon receiving such notification, or if you believe your privacy rights have otherwise been violated, you may file a complaint with Birmingham Maple Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact the Privacy Officer at the address listed at the end of this Notice. All complaints must be submitted in writing.

You will not be penalized or retaliated against for filing a complaint.

If you have any questions about this Notice, please contact:

Privacy Officer – Birmingham Maple Clinic, Inc.
2075 West Big Beaver Road
Suite 520
Troy, Michigan 48084