STANLEY S. ROLAND, D.O., P.C. (“SSR”)
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.
Dr. Roland and his staff take the privacy of your health information seriously. We are required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This Notice is provided to tell you about our duties and practices with respect to your information. We are required to abide by the terms of this Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe different ways that We use and disclose your health information without your authorization. For each category We explain what We mean and give some examples. 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.
For Treatment. We may use health information about you to provide you with treatment, health care or other related services. We may disclose your health information to doctors, nurses, aids, technicians or other Covered Entity employees who are involved in taking care of you. Additionally, We may use or disclose your health information to manage or coordinate your treatment, health care or other related services. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
For Payment. We may use and disclose your health information to bill and collect for the treatment and services we provide to you. We may send your health information to an insurance company or other third party for the payment purposes. For example, your health plan may request and receive information on dates of service, the services provided and the medical condition being treated. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover treatment.
For Health Care Options. We may use and disclose your health information for health care operations. These uses and disclosures are necessary to run the office, to make sure you receive competent, quality health care and to maintain and improve the quality of health care we provide.
As Required By Law. We will disclose your health information when required to do so by federal, state or local law.
For Public Health Purposes. We may disclose your health information for public health activities. While there may be others, public activities generally include the following:
Preventing or controlling disease, injury or disability;
Reporting births and deaths;
Reporting defective medical devices or problems with medications;
Notifying people of recalls of products they may be using;
Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
About Victims of Abuse. We may disclose your health information to notify the appropriate government authority if we believe you have 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.
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.
Judicial Purposes. We may disclose your health information in response to a court or administrative order. We may disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell you about the request, in which you were given an opportunity to object to the request, or to obtain an order protecting the information request.
Law Enforcement. We may release health information if asked to do so by a law enforcement official, if such disclosure is:
Required by law;
In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness or missing person;
About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
About a death we believe may be the result of criminal conduct;
About criminal conduct at Dr. Roland’s office; or
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities. We may release your health information to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or for the conduct of special investigations.
Custodial Situations. If a correctional institution or law enforcement authority makes certain representations, we may disclose your health information to a correctional institution or law enforcement official.
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 provide appointment reminders. If you do not wish Dr. Roland to contact you about treatment alternatives, health-related benefits or appointment reminders, you must notify in writing and state which of those activities you wish to be excluded from, to the person listed on the last page of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding health information we maintain about you:
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Privacy Official at 610 North Main Street, Lapeer MI 48446. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.
Right to Request Confidential Communications. Typically, we communicate with you regarding your health care either through your home phone or through the mail at your home address. You have the right to request that we communicate with you or your responsible party about your health care in an alternative way or at a certain location.
To request confidential communications, you must make your request in writing to Privacy Official at 610 North Main Street, Lapeer MI 48446. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care.
To inspect and copy health information that may be used to make decisions about you, you can submit your request in writing to Privacy Official at 610 North Main Street, Lapeer MI 48446. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
Right to Amend. You have the right to ask us to amend your health and/or billing information for as long as the information is kept by Dr. Roland.
To request an amendment, your request must be made in writing and submitted to Privacy Official at 610 North Main Street, Lapeer MI 48446. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the health information kept by Dr. Roland;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures that we have made of your health information.
To request this list of disclosures, you must submit your request in writing to the Privacy Official at 610 North Main Street, Lapeer MI 48446. Your request must state a time period which may not be longer that six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a twelve-month period will be free. For additional lists, during such a 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. You may obtain a copy of this Notice at our web site at:
www.stanleysroland-do.com. To obtain a paper copy of this Notice, contact Privacy Official at 610 North Main Street, Lapeer MI 48446.
WHO THIS NOTICE APPLIES TO
This Notice describes Dr. Stanley Roland’s practices and those of:
Any health care professional authorized to enter information into or consult your medical record.
All departments and units of Dr. Roland.
Any member of a volunteer group we allow to help you.
All employees, staff and other personnel of Dr. Roland.
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, and you are still with Dr. Roland, we will offer you a copy of the current Notice in effect.
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:
Stanley S. Roland, D.O., P.C.
610 North Main Street
Lapeer, MI 48446
If you believe that your privacy rights have been violated, you should call the matter to our attention by 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.
The name and address of the person you can contact for further information concerning our privacy practice is:
Stanley S. Roland, D.O., P.C.
610 North Main Street
Lapeer, MI 48446
This Notice is effective on or after April 14, 2003.