Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES FOR MUNSTER MEDICAL IMAGING (referred to in this document as "the practice")

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.

This Notice of Privacy Practices (Notice) is being provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA).

This Notice describes how we may use and disclose your protected health information (PHI) to carry out testing, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI in some cases. Your "PHI" means any of your written and oral health information, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present, or future physical or mental health or condition.

Uses and Disclosures of PHI

The Practice may use your PHI for purposes of providing diagnostic testing, obtaining payment for testing, and conducting health care operations. Your PHI may be used or disclosed only for these purposes unless the Practice has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA Privacy Regulation or State Law. Disclosures of your PHI for the purpose described in this Notice may be made in writing, orally, or by facsimile.

A. Diagnostic Testing. We will use and disclose your PHI to provide, coordinate, or manage your testing and any related services. This includes the coordination or management of your testing with a third party for treatment purposes. For example, we may disclose your PHI to a home health agency that is providing care in your home. We may also disclose PHI to other physicians who may be treating you or consulting with your physician with respect to your care. In some cases, we may also disclose your PHI to an outside treatment provider for purposes of the treatment activities of the other provider.

B. Payment. Your PHI will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurer to get approval for the testing that has been recommended. For example, if a hospital admission is recommended, we may need to disclose information to your health insurer to get prior approval for the hospitalization.

We may also disclose PHI to your insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for your services, we may also need to disclose your PHI to your insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider’s payment activities.

C. Operations. We may use or disclose your PHI, as necessary, for our own health care operations in order to facilitate the function of the practice and to provide quality care to all patients. Health care operations include such activities as:

Quality assessment and improvement activities.

Employee review activities.

Accreditation, certification, licensing or credentialing activities.

Review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs.

Business management and general administrative activities.

In certain situations, we may use or disclose your PHI to assist health care providers in connection with their treatment or payment activities, or to assist other covered entities in connection with certain health care operations. For example, we may disclose your PHI to a health care provider when needed by the provider to render treatment to you, and we may disclose PHI to another covered entity to conduct health care operations in the areas of quality assurance and improvement activities, or accreditation, certification, licensing, or credentialing. This also means that we may disclose or share your PHI with other health care programs or insurance carriers (such as Medicare, Blue Cross Blue Shield, etc.) or health plans in order to coordinate benefits, if you or your family members have other health insurance or coverage.

D. Disclosures to Personal Representatives. We will disclose your PHI to an individual who has been designated by you as your personal representative and who has qualified for such designation in accordance with applicable law. Prior to such a disclosure, however, we must be given written documentation that supports and establishes the basis for the personal representation. We may elect not to treat the person as your personal representative if we have a reasonable belief that you have been, or may be, subjected to domestic violence, abuse, or neglect by such person; that treating such person as your personal representative could endanger you; or if we determine, in the exercise of professional judgment, that it is not in your best interest to treat the person as your personal representative.

E. Other Uses and Disclosures. As part of diagnostic testing, payment and healthcare operations, we may also use or disclose your PHI for the following purposes: To remind you of an appointment.

Uses and Disclosures

Beyond Diagnostic Testing, Payment, and Health Care Operations Permitted Without Authorization or Opportunity to Object Federal privacy rules allow us to use or disclose your PHI without your permission or authorization for a number of reasons including the following:

A. When Legally Required. We will disclose your PHI when we are required to do so by any Federal, State, or local law, including disclosures to the Secretary of Health and Human Services in connection with determining whether the practice is in compliance with the applicable laws.

B. When There Are Risks to Public Health. We may disclose your PHI for the following public activities and purposes:

To prevent, control, or report disease, injury or disability as permitted by law.

To report vital events such as birth or death as permitted or required by law.

To conduct public health surveillance, investigations and interventions as permitted or required by law.

To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.

To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.

To report to an employer information about an individual who is a member of the workforce as legally permitted or required.

C. To Report Abuse, Neglect, or Domestic Violence. We may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

D. To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

E. In Connection with Judicial and Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a signed authorization (in a format approved by the Michigan Court Administrator).

F. For Law Enforcement Purposes. We may disclose your PHI to a law enforcement official for law enforcement purposes as follows:

As required by law for reporting of certain types of wounds or other physical injuries. Pursuant to court order, court-ordered warrant, subpoena, summons, or similar process. For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.

Under certain limited circumstances, when you are the victim of a crime.

To a law enforcement official if the practice has a suspicion that your death was the result of criminal conduct.

In an emergency in order to report a crime.

G. To Correctional Institution or Law Enforcement Officials. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to the correctional institution or to a law enforcement official for:

(1) the institution to provide health care to you;

(2) your health and safety, and the health and safety of others; or

(3) the safety and security of the correctional institution.

H. To Coroners, Funeral Directors, and for Organ Donation. We may disclose PHI to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation and transplantation purposes.

I. For Research Purposes. We may use or disclose your PHI for research when the use or disclosure for research has been approved by an institutional review board or privacy board that has reviewed the research proposal and research protocols to address the privacy of your PHI.

J. In the Event of A Serious Threat to Health Or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

K. For Specified Government Functions. In certain circumstances, the Federal regulations authorize the practice to use or disclose your PHI to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, and law enforcement custodial situations.

L. For Worker's Compensation. The practice may release your health information to comply with the worker’s compensation laws or similar programs.

M. To Business Associates. Practice contracts with service providers, called business associates, to perform various functions on its behalf. For example, we may contract with a service provider to perform the administrative functions necessary to pay your medical claims. To perform these functions or to provide the services, business associates will receive, create, maintain, use, and/or disclose PHI, but only after practice and the business associate agree in writing to contract terms requiring the business associate to appropriately safeguard your information and to comply with other applicable legal requirements.

Uses and Disclosures Permitted Without Authorization But With Opportunity to Object.

We may disclose your PHI to your family member or a close
personal friend if it is directly relevant to the person's involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your
location, condition or death.

You may object to or request a restriction on these disclosures. If you do not object to these disclosures or place restrictions on them, or we can infer from the circumstances that you do not object or we determine in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person's involvement with your care, we may disclose your PHI as described.

Uses and Disclosures Which You Authorize.

Other than stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

Your Rights.

You have the following rights regarding your health information:

A. The Right to Inspect and Copy Your PHI. You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the PHI. A "designated record set" contains the medical and billing records and any other records that your physician and the practice, uses for making decisions about you.

Under Federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or for use in civil, criminal, or administrative action or proceeding; and PHI that is subject to a law that prohibits access to PHI. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

We may deny your request to inspect or copy your PHI if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.

To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed at the end of this Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request as allowed by law. Please contact our Privacy Officer if you have questions about access to your medical record.

B. The Right to Request a Restriction on Uses and Disclosures of Your PHI. You have the right to request that we do not to use or disclose certain part of your PHI for the purposes of diagnostic testing, payment or health care operations by contacting the Privacy Officer. You also have a right to request that we not disclose your health information to family members or others involved in your health care as described in this Notice. Your request must include the PHI you wish to limit, whether you want to limit our use, disclosure, or both, and (if applicable), to whom you want the limitations to apply (for example, disclosures to your spouse).

The practice is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the practice agrees to the requested restriction, we may not use or disclose your PHI in violation of the agreed upon restrictions. We may terminate our agreement to a restriction upon providing notice to you, except that such termination will only be effective with respect to PHI created or received after we provide such notice to you.

C. The Right to Request to Receive Confidential Communications from us by Alternative Means or at an Alternative Location. You have the right to request that we communicate with you in certain ways. Your request must specify the alternative means or location for communication with you. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer.

D. The Right to Request Amendment of Your PHI. You may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.

E. The Right to Receive an Accounting of Disclosures. You have the right to request an accounting of certain disclosures of your PHI made by the practice. This right applies to disclosures for purposes other than testing, payment and health care operations as described in this Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. We will notify you in advance of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

F. The Right to Obtain a Paper Copy of this Notice. Upon request, we will provide a separate paper copy of this Notice even if you have already received a copy of the Notice or have agreed to accept this Notice electronically.

Our Duties

The practice is required by law to maintain the privacy of your health information and to provide you with this Notice of our duties and privacy practices. We are required to abide by the terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that we maintain. If the practice changes its Notice, we will provide a copy of the revised Notice by sending a copy of the Revised Notice via regular mail or through in-person contact.

Complaints

You have the right to express complaints to the practice and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the practice by contacting the practice's Privacy Officer verbally or in writing, using the contact information below.

We encourage you to express any concerns you may have regarding the privacy of your information.

You will not be retaliated against in any way for filing a complaint.

Contact Person

The practice's contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Officer. Information requests or questions regarding matters covered by this Notice can be addressed to our Privacy Officer.

Privacy Officer, Munster Medical Imaging
625 Ridge Rd, Suite A, Munster, IN 46321
Phone: (219) 513-9035 · Fax: (219) 513-9269