Notice of Privacy Practices
Please review this form and sign below.
- 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.
Your Health Information:This notice applies to the information and records we have about you, your health, and the care and services you receive from i’move. This Protected Health Information (PHI) may be either created or received by i’move and may be in the form of written or electronic records or spoken words, and may include information about your health history, symptoms, examinations, test results, diagnoses, treatments, procedures, related billing activity, and similar types of health-related information.
How We May Use and Disclose Health Information About You:
For Treatment: We may use and disclose PHI for your treatment and to provide you with treatment-related health care services. For example, we may disclose PHI to doctors, nurses, or other medical personnel who are involved in your medical care so they provide the appropriate care.
For Payment: We may use and disclose PHI so that we or others may bill and receive payment from you, an insurance company, or a third party for the treatment and services you receive.
For Health Care Operations: We may use and disclose PHI to ensure that you and our other patients receive quality care. For example, we may use PHI to evaluate performance of our staff in caring for you and determine if the most appropriate care was given. We may also provide PHI to health plans that provide you insurance coverage to improve care, reduce cost, and comply with the law.
Family and Friends: With the patient’s permission, or in some emergencies when consent cannot be attained, we may use and disclose PHI to family members, friends, or others to aid in treatment or to collect payment for services.
When Required by Law: We may use or disclose PHI when required by law. For example, PHI may be released when required by privacy laws, workers’ compensation or similar laws, public health laws, court or administrative orders, certain subpoenas, certain discovery requests, or other laws, regulations, or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials or correctional institutions for an inmate, lawful detainee, suspect, fugitive, material witness, missing person, or a victim or suspected victim of abuse, neglect, domestic violence, or other crimes. We may disclose PHI to the extent reasonably necessary to avert a serious threat to a patient’s health or safety or the health or safety of others.
Health Oversight Activities: We may use or disclose PHI to a health oversight agency for audits, investigations, or other oversight activities. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Research: We may use or disclose PHI for research projects that are subject to a special approval process. We will ask you for permission if the researcher will have access to your name, address, or other information that reveals who you are or will be involved in your care in any way.
Lawsuits and Disputes: If you are involved in legal proceedings, we may disclose PHI in response to a court or administrative order, including response to a subpoena.
Military, Veterans, National Security, and Intelligence. If you are or were a member of the armed forces or part of the national security or intelligence communities, either domestic or foreign, we may be required by military command or other government authorities to release PHI about you.
Public Health Risks: We may disclose PHI about you in order to prevent or control disease, injury or disability, or to report suspected abuse or neglect, non-accidental physical injuries, reactions to medications, or problems with products.
Other Uses and Disclosures of Health Information:
Without your permission, we are prohibited to use or disclose your PHI for marketing purposes, and we may not sell your PHI without your authorization.
Your Rights Regarding Health Information About You:
Right to Access and Copies: In most cases, a patient has the right to review or to purchase copies of PHI. This includes medical and billing records either in paper or electronic form. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review. Please contact our Privacy Officer in writing to request access to or copies of PHI or with inquiries regarding our copying fees.
Right to Amend: If you believe your PHI is incomplete or incorrect, you may ask us to amend the information. You may request the amendment as long as the information is kept by or for our office. Requests must be made in writing to our Privacy Officer.
Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we made of PHI for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To obtain this list, you must submit your request in writing to our Privacy Officer.
Right to Request Restrictions: You have the right to request a restriction or limitation on PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care or the payment of your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make a written request to Our Privacy Officer. We are not required to agree to your request in the case that your PHI is needed to provide you with emergency treatment or we are required by law to disclose it.
Out-of-Pocket Payments: If you have paid out-of-pocket for any services i’move has provided, you have the right to ask that we not share any PHI with your health plan for payment or health care operations purposes. THIS REQUEST MUST BE MADE AT THE TIME OF YOUR FIRST VISIT.
Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may request that we contact you only by mail or at work. To request confidential communication, you must do so in writing to our i’move Privacy Officer, noting the manner in which you would like to be communicated with.
Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this notice at any time. You may also find a copy of this notice on our web site @ www.imovedaily.com/getstarted.
Changes to This Notice:
We reserve the right to change this notice and make the new notice apply to PHI that we already have as well as any PHI we receive in the future. We will post a copy of our current notice at our office and on our web site.
Breach of Protected Health Information:
We will inform you if there is a breach of your PHI.
If you believe your privacy rights have been violated, you may contact the Privacy Officer in writing at this location. Or you may contact the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.
Martin Sytsema (i’move Privacy Officer)
18000 Cove St, Spring Lake, MI 49456
By typing your name below, you are signing this form electronically.
I confirm that I have reviewed and been offered a paper copy of the i'move Notice of Privacy Practices.