3537 West Front Street, Suite I, Traverse City, MI 49684
(231) 935-8950  phone
(231) 935-8868  fax
 

Thirlby Clinic Privacy Statement and Agreement

Date: December 5, 2013
Revised Date Implementation: 12/05/2013

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.
You are receiving health care at Thirlby Clinic.
We are required by law to maintain the privacy of your individually identifiable patient health information, which is often referred to as "protected health information" ("Health Information"). We are also required by law to provide you with this Notice of Privacy Practices ("Notice"), which described our legal duties and privacy practices concerning your Health Information. We will only use or disclose your Health Information as permitted or required by applicable HIPAA, state law and the terms of this Notice that is currently in effect.
Thirlby Clinic understands that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly.
This Notice applies to the delivery of health care by Thirlby Clinic medical staff in the office. Your other doctors may have different notices and policies about the use and disclosure of your Health Information created in his or her office or clinic.
  1. Permitted Use or Disclosure Not Requiring Your Permission or Authorization
    1. Treatment: Thirlby Clinic may use and disclose your Health Information in providing and coordinating your health care.
      For example, Thirlby Clinic may disclose your Health Information to Thirlby Clinic workforce members, your attending physician, consulting physician(s), nurses, pharmacists, technicians, medical students, dieticians, and other health care providers who have a need for such information for your care and treatment.
      Your health care providers may share your Health Information to coordinate your care and specific services, such as lab work, x-rays and prescriptions.
    2. Payment: Thirlby Clinic may disclose Health Information about you to your insurance company and its agents to be paid for the services you were provided and assist others who provide you with care to get paid for that care. For example, Thirlby Clinic may need to release your diagnoses, tests or treatment you will receive, as well as provide copies of your health record to your insurance company or its agents to obtain prior approval or to determine whether your insurance will cover the treatment or tests.
      Thirlby Clinic may disclose Health Information to collection agencies and other subcontractors engaged in obtaining payment for care that was provided to you.
    3. Health Care Operations: Thirlby Clinic may use and disclose Health Information about you for our operations including, for example, accounting, legal, quality review, utilization review, medical review, internal auditing, accreditation, certification, our licensing or credentialing activities, or for educational purposes. This information will be disclosed to Thirlby Clinic's workforce, physicians, or agents. These uses and disclosures are necessary to run Thirlby Clinic and to improve the quality of care our patients receive. For example, we may use and disclose your demographic information, diagnosis, treatment plan and health status for population based activities relating to improving health care or reducing health care costs, protocol development, case management and care coordination.
      Thirlby Clinic may also use and disclose your PHI to support the sale, transfer, or other corporate restructuring of Thirlby Clinic's assets.
    4. Appointment Reminders: Thirlby Clinic may use and disclose your Health Information to contact you as a reminder that you have an appointment for treatment or medical care at Thirlby Clinic.
    5. Treatment Alternatives: Thirlby Clinic may use and disclose your Health Information to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.
    6. Inmates or in Law Enforcement Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Thirlby Clinic may disclose your PHI to the correctional institution or law enforcement official.
  2. Permitted Use or Disclosure with an Opportunity for You to Agree or Object
    1. Family/Friends: Thirlby Clinic may disclose health information about you to a friend or family member who is involved in your medical care. We may also give health information to someone who helps pay for your care. In addition, we may disclose health information about you to an agency assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You have a right to request that your health information not be shared with some or all of your family or friends.
  3. Use or Disclosure Requiring Your Authorization

    Thirlby Clinic will obtain your written authorization to disclose your Health Information as described below. Not ever use or disclosure in a category may be listed.
    1. Psychotherapy Notes: Thirlby Clinic will obtain your written authorization for any use or disclosure of psychotherapy notes, except as permitted by law.
    2. Promotional Communications, Fundraising, and Marketing: Thirlby Clinic will obtain your written authorization for most marketing activities and disclosures that constitute the sale of your Health Information before disclosure. Thirlby Clinic does not share or sell your Health Information to companies that sell health care products or services for use by such companies to contact you.
    3. Other Uses: Thirlby Clinic will obtain your written authorization to use Health Information about you for any uses or disclosures that are not for treatment, payment or health care operations or otherwise required by law, and other uses and disclosures not described in this Notice will be made only with your written authorization.
    4. Revocation: You have the right to revoke an authorization at any time, by putting your request in writing and submitting the request to the Medical Records department. This revocation will be effective for future disclosures of your Health Information. However, the revocation will not be effective for information that we have already used or disclosed.
  4. Use or Disclosure Permitted by Public Policy or Law without your Authorization
    1. Law Enforcement Purposes: Thirlby Clinic may disclose your Health Information for law enforcement purposes, which may include responding to a court order or subpoena, identifying a criminal suspect or a missing person, or providing information about a crime victim or possible criminal conduct as part of a criminal investigation.
    2. Required by Law: Thirlby Clinic may disclose Health Information about you when required by federal, state, or local law or public health officials to make reports or other disclosures. For example, these disclosures may be made for all of the following purposes, as they may apply to you: (a) community and public health activities such as disease control; (b) administrative agency oversight for such things are audits, investigations, licensure, drug diversion programs, and fraudulent prescription activity; (c) specialized government functions such as military and veteran's activities, national security and intelligence activities, and protective services for the President and others; and (d) workers' compensation or similar programs.
    3. Coroners, Medical Examiners, Funeral Directors: Thirlby Clinic may disclose your Health Information to a coroner, medical examiner, or funeral director as necessary to carry out their duties.
    4. Organ Procurement: Thirlby Clinic may disclose your Health Information to an organ procurement organization or entity for organ, eye or tissue donation purposes when donation has been authorized or to verify that appropriate organ procurement procedures were followed.
    5. Health or Safety: Thirlby Clinic may use and disclose Health Information about you to avert a serious threat to your health and safety or the health and safety of another person or the public.
  5. Your Health Information Rights
    You have the following rights concerning the Health Information we maintain about you:
    1. Right to Inspect and Copy: You have the right to inspect and receive a copy of your Health Information that we create or receive about you so long as we maintain your Health Information. Usually, this includes medical and billing records, but does not include: psychotherapy notes (those notes kept in a personal file by a therapist or physician and not part of the formal medical record); information that may be used in anticipation of, or that will be used in a civil, criminal or administrative action or proceeding; and where prohibited or protected by law.
      Thirlby Clinic may deny your request for access to your Health Information without giving you an opportunity to review that decision if:
      1. You do not have the right to inspect the information, or it is otherwise prohibited or protected by law;
      2. You are an inmate at a correctional institution and obtaining a copy of the information would risk the health, safety, security, custody or rehabilitation of you or other inmates; or the disclosure of the information would threaten the safety of any officer, employee or other person at the correctional institution or who is responsible for transporting you;
      3. Thirlby Clinic obtained your Health Information from someone other than the health care provider under a promise of confidentiality and the access requested is reasonably likely to reveal the source of the information; or
      4. Under other limited circumstances. In these instances, however, Thirlby Clinic will allow the review of its decision by a health care professional of its choosing and who was not involved in the original decision to deny your request.
      Thirlby Clinic may charge a reasonable fee for the costs of copying, mailing or other supplies and labor associated with your request as allowed by law or regulation. You must make your requests to access and copy your Health Information in writing to Thirlby Clinic. Thirlby Clinic will respond to your request within 30 days of its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 60 days of its receipt.
    2. Right to Amend: You have the right to amend your Health Information for as long as Thirlby Clinic maintains it. However, we may deny your request for amendment if:
      1. Thirlby Clinic did not create the information;
      2. The information is not part of the designated record set;
      3. The information would not be available for your inspection (due to its condition or nature); or
      4. The information is accurate and complete.
      If Thirlby Clinic denies your request for changes in your Health Information, we will notify you in writing with the reason for the denial. We will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that we include your request for amendment and the denial any time that Thirlby Clinic discloses the information that you wanted changed. Thirlby Clinic may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.
      You must make your request for amendment of your Health Information in writing to Thirlby Clinic, including your reason to support the requested amendment. Thirlby Clinic will respond to your request within 60 days of its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 90 days of its receipt.
    3. Right to an Accounting: You have a right to receive an accounting of the disclosures that Thirlby Clinic made of Health Information about you, except for the following disclosures:
      1. To carry out treatment, payment or health care operations;
      2. Made to you;
      3. For national security or intelligence purposes;
      4. To correctional institutions or law enforcement officials in custodial situations; or
      5. That occurred prior to April 14, 2003.
      For each disclosure, you will receive: the date of the disclosure, the name of the receiving organization and address if known, a brief description of the Health Information disclosed and a brief statement of the purpose of the disclosure or a copy of the written request for the information, if there was one.
      You must make your request for an accounting of disclosures of your Health Information in writing to Thirlby Clinic's Medical Records Department. You must include the time period of the accounting, which may not be longer than 6 years prior to the date for your request. We will respond to your request within 60 days from its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 90 days of its receipt.
    4. Right to Request Restrictions: You have the right to request restrictions and limitations on the Health Information we use or disclose about you to carry out treatment, payment, or health care operations, including:
      1. To a health plan with respect to healthcare for which you have paid out of pocket in full prior to service being initiated. The request must be in writing.
      2. Limited information in the facility directory.
      We are not required by federal regulation to agree to your request and may be prohibited by law from agreeing your request, such as, in the event of reporting for public health activities. You must make your request for a restriction in writing to Thirlby Clinic. Your request must include (a) what information you want to restrict; (b) whether you want to limit our use, disclosure or both; and (c) to whom you want the restrictions to apply.
    5. Right to Confidential Communications: You have the right to request that we communicate with you about your Health Information by alternative means or at alternative locations. For example, you may request that we only contact you at work or by mail.
    6. Right to Breach Notification: You have the right to be notified in the event that Thirlby Clinic or one of its business associates discovers a breach involving your unsecured Health Information.
    7. Right to Receive a Copy of this Notice: You have the right to receive a paper copy of this Notice of Privacy Practices, upon request.
  6. Complaints
    If you believe your privacy rights have been violated, you may file a complaint with Thirlby Clinic and /or with the Secretary of the Department of Health and Human Services, Office of Civil Rights. For more information, or to voice a privacy complaint for an incident at Thirlby Clinic please contact Thirlby Clinic's Privacy Officer, at:
    3537 West Front Street, Suite I
    Traverse City, MI 49684
    (231) 935-8960
    Thirlby Clinic assures you that there will be no retaliation for filing a complaint.
  7. Sharing and Joint Use of your Health Information
    In the course of providing care to you and in furtherance of Thirlby Clinic's mission to improve the health of the community, Thirlby Clinic may share your Health Information with other organizations as described below who have agreed to abide by the terms described below:
    1. Medical Staff: The medical staff and Thirlby Clinic participate together in an organized health care arrangement to deliver health care to you. Thirlby Clinic and its medical staff have agreed to abide by the terms of this Notice with respect to Health Information that we create or receive in delivering health care services to you.
    2. Business Associates: Thirlby Clinic may use and disclose your Health Information to companies, agents, and individuals (known as business associates) contracted to perform certain functions on its behalf.
      Whenever an arrangement between Thirlby Clinic and another company involves the use or disclosure of your Health Information, that business associate is required by HIPAA to keep your information confidential, to train the workforce members who have access to your Health Information on complying with HIPAA, and to implement certain policies and procedures to keep you information confidential.
      Thirlby Clinic participates in an organized health care arrangement for utilization review and quality assessment activities involving PHI. Thirlby Clinic abides by the terms of this Notice with respect to PHI created or received as part of utilization review and quality assessment activities of Thirlby Clinic and its members.
    3. Community Registry and Health Information Exchange. Thirlby Clinic may participate in one or more health information exchanges ("HIE") and may electronically share your Health Information for treatment, payment, and health care operations purposes with other participants in the HIEs.
      For example, Thirlby Clinic participates in a Community Registry ("Registry") operated by Northern Physicians Organization, Inc. ("NPO"). This Registry facilitates the electronic exchange of health information between health care providers participating in this Registry for patient treatment, health care operations, and other legally permissible purposes.
      This Registry is a tool that we and others involved in your care can use to carry out your treatment and engage in activities to help manage your care such as coordinating your care, conducting quality assessment and improvement activities, and related planning and management activities that do not include treatment.
      To the extent permitted by law, Thirlby Clinic may disclose Health Information about you through the Registry to others involved in your care, which may include other doctors, hospitals, pharmacies, or insurance companies. Thirlby Clinic may also receive Health Information about you through the Registry that was created by your other health care providers.
      Your participation in the HIEs is voluntary and subject to your right to opt-out. If you opt out, your Health Information will no longer be accessible through the HIEs in which Thirlby Clinic participates, but your opt out does not affect the Health Information that was disclosed through an HIE prior to your opt out.
    4. Changes to this Notice: Thirlby Clinic reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all Health Information that it creates and maintains about you. Thirlby Clinic will provide you with the revised Notice at your first visit following the revision of the Notice.
  8. Review of the Notice of Privacy Practice
    This Notice of Privacy Practices was reviewed and updated in 2013, and is reviewed each 2 years. The most current version of this Notice is posted on Thirlby Clinic's internet site.