PRIVACY NOTICE TO OUR PATIENTS

REGARDING MEDICAL INFORMATION ABOUT YOU AND HOW IT MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION.

PLEASE REVIEW IT CAREFULLY! Effective Date: April 14, 2003

If you have any questions about this information, please contact the office’s “Privacy Officer”

WHO WILL FOLLOW THIS NOTICE:

All employees, staff and those involved with your treatment, payment or the operations of our office

OUR COMMITMENT TO YOU:

We understand that information about you is personal and confidential. We have always used, stored and shared your information responsibly, and will continue to do so. This new notice is in response to a new federal law regarding patient information and applies to all your records generated by our practice, whether made by us directly or received on your behalf from your other healthcare providers.

WE ARE REQUIRED BY LAW TO:

Make sure that medical information that identifies you is kept private.

We are required to provide this notice of our legal duties and privacy practices with respect to your information; and follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose your information. For each category we will explain what we mean and try to give you an example of what is covered. Not every use or disclosure in a category will be listed. All the ways we are permitted to use and disclose your information will fall within one of the categories.

FOR TREATMENT: We may use medical information about you to provide you with treatment or services. We may disclose covered information about you to others who also are involved in your treatment or taking care of you. i.e. labs, physical therapy and other healthcare Providers. , or your family or friends who are involved in your care decisions.

FOR PAYMENT: We may use and disclose covered information about you so that the treatment and services you receive can be billed to and payment may be collected from you, your insurance company or a third party. I.e., we may need to give your health plan information about your treatment, so your health plan will pay us or reimburse you for the service.

FOR HEALTHCARE OPERATIONS: The law permits us to use and disclose covered information about you for the operation of our practice. These uses and disclosures are necessary to run the practice and make sure all patients receive quality care. The following are areas of how we may use and disclose your information to operate this office:

· Appointment reminders, by mail or phone

· Sign in sheets to identify you are present for your appointment (s)

· Posted schedules, which may include the treatment planned for you.

· To provide you with information about treatment alternatives that may be of interest to you.

Research: Under certain circumstances, we may use and disclose medical information about you for research projects. We will ask for your specific authorization if the research information includes items of your identity.

As Required by Law: We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health & Safety: We may use & disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health & safety of another person or the public.

OTHER SPECIAL SITUATIONS

Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to

Workers Compensation: We may release medical information about you for worker’s compensation or similar programs. These programs provide benefits for work related injury or illness.

Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:

* To prevent or control disease, injury or disability * To report births and deaths

* To report child or adult abuse, neglect or exploitation * To report reactions to medications or problems with a product

* To notify people of recalls of products that they may be using.

* To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

* To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will make this disclosure when required or authorized by law.

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. For example, audits, investigations, inspections, peer review, credentialing and licensure.

Lawsuits and Disputes: In response to a court or administrative order, subpoena, discovery request or other lawful process.

Law Enforcement: We may release medical information if asked to do so by a law enforcement official:

· 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 a 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 the practice and

· In emergency situations to report a crime, the location of a crime or victim (s), or the identity or location of the person who committed the crime.

Coroners, Medical Examiners, Funeral Directors

This may be necessary, for example, to identify a deceased person or determine the cause of dearth.

National Security and Intelligence Activities. We may release medical information about you to authorize federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President & Heads of State

We may disclose your information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads, or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution of law enforcement official. This release would be necessary

For the institution to provide you with health care

2. To protect your health and safety of the health and safety of others

3. For the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding medical information we maintain about you.

RIGHT TO INSPECT AND COPY : You have the right to inspect and copy medical information that may be used to make decisions about your care. This usually includes medical, dental and billing records.

To inspect and copy your medical information, you must submit your request in writing to the office manager. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and staff time associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances.

RIGHT TO AMEND: If you feel that medical information about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the practice. To request an amendment, your request, and the reason that supports your request, must be made in writing and submitted to the office manager. We may deny your request if it is not in writing or: The information was not created by us, unless the person or entity that created the information is no longer available, not part of the medical information kept by or for the practice, The information is not part of the information which you would be permitted to inspect or copy; or The information is accurate and complete

RIGHT TO AN ACCOUNTING OF DISCLOSURES. This is a list of the disclosures we made of your medical information that was not related to treatment, payment or operations of the office as we have listed. To request this accounting of disclosures, you must submit your request in writing to the office manager, stating a time period of not longer than 6 years, not including dates before February 2003. You are entitled to one accounting without charge. You may be charged for subsequent lists. You will be told the cost involved , and may withdraw or modify your request.

RIGHT TO REQUEST RESTRICTIONS You have the right to request a restriction or limit on the medical information we use of disclose about you for treatment, payment or office operations. You also have the right to request such restrictions on information we may disclose to someone involved in your care, like a family or friend. i.e. you may ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request.

If we do agree, we will comply with your request unless the information is needed for emergency treatment. To request such restrictions, you must make your request in writing to the office manager. In your request you must tell us

What information you want to limit; Whether your limitations include use, disclosure or both;. To whom you want the limits to apply

for example disclosures to a particular family member. The reason for your request for restrictions.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS. You have the right to request that we communicate with you about medical matters in a certain way at a certain location. I.e., you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the office manager. It is not necessary for you to give a reason for this request. We will accommodate your request if reasonable. Your request must specify how or where you wish to be contacted.

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.

Simply ask the receptionist for a copy.

CHANGES TO THIS NOTICE. We reserve the right to change this notice. We reserve the right to make the revised or changed notice 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 the notice that is in effect in the office and have a copy of the current notice available for you upon request.

COMPLAINTS. You have the right to file a compliant without being penalized. Our practice cares about you and your rights. We have provided extensive training to our staff and reviewed our office procedures to protect your personal medical information., and keep it private.

If you believe your privacy rights have been violated, you may file a complaint with the office manager. Please submit your concerns in writing. All complaints will be followed through a practice review process. We take your concerns very seriously and will make appropriate efforts to resolve them. You also have the right to file a complaint regarding privacy violations to the Secretary of Health & Human Services.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose the medical information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission, and are required to retain our records of the care we provided to you

We welcome this opportunity to involve you in the operations of our office. We welcome your comments, and will continue to work with you to provide the best care we can.

We will be asking you to sign an acknowledgement of our office providing you with this Privacy Information as required by the new Federal Health Insurance and Portability Act. Your signature does not obligate you in any way. It simply verifies that we have followed the new policy in addition to the Privacy standards in Michigan Law and in our practice.

Marvin Herschfus D.D.S.

Thank You for your continued trust in our care.