Notice of Privacy Practices for Protected Health Information

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.

Uses and Disclosures

TREATMENT. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of lab tests and procedures will be available in your medical record to all health professionals who may provide treatment or may be consulted by staff members.

PAYMENT. Your health information may be used to seek payment from your health plan, or other source such as auto insurer, or credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, services provided, and medical condition being treated.

HEALTH CARE OPERATIONS. Your health information may be used as necessary to support the day-to-day activities and management of Family Surgical. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

LAW ENFORCEMENT. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting.

PUBLIC HEALTH REPORTING. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state's public health department.

VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE. We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.

OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of you decision to revoke your authorization.

Your Health Information Rights
The health and billing records we maintain are the physical property of the doctor's office. You have the following rights with respect to your Protected Health Information:

1. The right to request restrictions on the use and disclosure of your protected
   health information.
2. The right to receive confidential communications concerning your medical condition and treatment.
3. The right to inspect and copy your protected health information by providing a written request to our office. You may obtain a form from us and your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
4. The right to amend or submit corrections to your protected health information. If we deny this request to amend, you may file a statement of disagreement and require that this be attached in all future disclosures.
5. The right to receive an accounting of how and to whom your protected health information has been disclosed.
6. The right to receive a printed copy of this notice.

Family Surgical's Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.

RIGHT TO REVISE PRIVACY PRACTICES
As permitted by law, we reserve the right to amend or modify our privacy practices and policies. These changes in our practices and policies may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

TO REQUEST INFORMATION OR FILE A COMPLAINT
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Julie Jeffery, Privacy Officer, Family Surgical, 3620 Capital Ave., S.W., Suite B, Battle Creek, MI 49015. If you believe that your privacy rights have been violated, you should call the matter to our attention be sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Additionally, you may file a written complaint to the Secretary of Health and Human Services, Tommy Thompson, Department of Human Services, 330 Independence Ave., SW, Washington, DC 20201.

This notice is effective on and after April 14, 2003.