Summary of Notice of Privacy Practices

Effective April 14, 2003, Revised February 25, 2015

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

Uses and Disclosures of Health Information

We are committed to protecting your medical information. We create a record of the care and services you receive at this office. We use this information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.

We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

We may contact you by phone to provide appointment reminders. We may leave voicemail messages on your answering machine for these reminders and certain test results. We may disclose your health information with immediate family members known to be involved in your care.

•  Please choose one of the following options below:

•  __________ I authorize Lakeshore Allergy PC to leave information at the phone number indicated below regarding the patient's care, including lab and diagnostic test results. Results may be given to any responsible person residing in the home that answers the telephone, or calls us for the test results. A message may be left on voicemail if there is no answer.

PHONE NUMBER: _____________________

•  __________ I do NOT want information regarding any aspect of patient's health care given to ANY person, EXCEPT myself. A voicemail can be left for me to return the phone call from the office of Lakeshore Allergy PC. No personal health information may be spoken on the voicemail.

We reserve the right to revise this Notice. Any revised Notice will be effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of any revised Notice in this office. You can also request a copy of our Notice at any time.

You're Health Information Rights

Within the limits provided by federal and state law, you have the right to inspect and obtain a copy of your health information that we have created. If you request copies, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. If you believe that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. 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 related administrative purposes.

You may request that we not use or disclose your information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it. You have the right to request confidential communications and alternative means or an alternative location for your health information. You have the right to a paper copy of this Notice. You may exercise any of the above rights by submitting a signed letter detailing your request and mailing or delivering the letter to our practice's Privacy Officer or the Practice Administrator.

Our Legal Duty

We are required by law to protect the privacy of your information, provide this Notice about our information practices, and follow the information practices that are described in this Notice.

Consent for Use and Disclosure of Your Health Information

Our purpose in asking you to sign this form is to document that we have informed you that this office may use and disclose all your health information in our possession (Collectively "Protected Health Information").

The uses and disclosures of your Protected Health Information by this office will be used in connection with your treatment, or obtaining payment for treatment and services that this office provides to you, and so that this office can conduct its health care operations.

For a more complete description of how this office may use or disclose your Protected Health Information, please carefully review the Notice of Privacy Practices that the office has prepared and is providing to you today. Please also see our Notice of Privacy Practices for a more detailed discussion of the meaning of "Treatment", "Payment" and "Health Care Operations".

You have the right to review our Notice of Privacy Practices prior to signing this consent. Please be advised that the Notice of Privacy Practices may be revised from time to time. Any such revision will be made available to you in our office or by contacting the Privacy Officer or the Practice Administrator at 616-738-4262.

You should also carefully review the Notice of Privacy Practices because it contains a list of rights that are available to you with respect to this office's use and disclosure of your Protected Health Information. These rights include your right to request restrictions on our use and disclosure of your Protected Health Information.

You have the right to revoke this consent at any time. If you wish to revoke this consent, you must do so in writing.

I give permission for the following people to receive my records:

 

More Information

If you have any questions about this Summary of Notice of Privacy Practices, please contact our practice's Privacy Officer or the Practice Administrator at 616-738-4262 or via regular mail at 3290 N. Wellness Dr., Building D, Ste. 180, Holland, MI 49424.

Complaints

If you are concerned that we have violated your privacy right, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer or the Practice Administrator. You may also send a written complaint to the U.S. Department of Health and Human Services. The Privacy Officer or the Practice Administrator can provide you with the appropriate address upon request. This office will not penalize you in any way for filing a complaint.

BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THIS CONSENT AND THIS OFFICE'S NOTICE OF PRIVACY PRACTICES. YOU FURTHER ACKNOWLEDGE THAT YOU HAVE RECEIVED A COPY OF THIS OFFICE'S NOTICE OF PRIVACY PRACTICES TO TAKE WITH YOU.

 

Print Patient NameDate of Birth
 
Patient SignatureDate
 
Patient/Legal Guardian SignatureDate
 

 

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