Effective Date: April 14, 2003
NOTICE DESCRIBES HOW ADVENT REHABILITATION MAY USE AND DISCLOSE YOUR HEALTH
INFORMATION AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
USING AND DISCLOSING YOUR HEALTH
Whenever you visit a
hospital, physician, or other healthcare provider, a record of
your visit and the care provided to you during that visit is
made. Typically, this record contains information regarding
your symptoms, examinations, tests performed (including the
results), diagnoses, treatment, and any current and future
treatment purposes. In addition, this record is usually used
to obtain payment for treatment provided to you, for
administrative purposes, and to evaluate the quality of the
care provided to you. This notice tells you the ways in which
we may use and disclose your medical information. This notice
also describes your rights and certain obligations we have
regarding the use and disclosure of your medical information.
Specifically, we may use or disclose certain identifiable
health information about you for reasons such as:
- Treatment. A means of
communication with other health professionals who contribute
to or participate in your care while you are a patient,
including doctors, nurses, technicians, therapy students,
therapists, and other clinical personnel involved in your
care, as well as those outside of our organization who may
be involved in your medical care after you leave our
facilities, such as family members, clergy, or others who
provide services that are part of your care. For example, we
may need to disclose information about whether you have
diabetes to a doctor treating you for a broken bone or an
infection because of the implications.
- Payment. A means by
which you or your insurance company can verify services
provided to you so that we may receive payment for those
services provided. For example, we may need to give your
health plan information about treatment you received in
therapy so the plan will pay us for the care provided.
- Operations. A source of data in our daily
operations as a health care provider. For example, we may
need to use your health information and record as a tool
in educating and assessing the competency of doctors, therapists,
and technicians who provide care here.
At times, information may be released from
your medical record that is not for the purposes of treatment,
payment, or operations. You have the right to restrict or
prohibit these disclosures. These situations include the following:
- We may contact you by
phone to provide appointment reminders, offer you
information about treatment alternatives, or other health
related benefits and services that may be of interest to
- The release of information for health
professional education or research studies that have been
approved by us.
At times we are required by law to release
your health information. These situations include the following:
- Release of
information to public health officials charged with
improving the health of our city, state, and nation, or
responsible for averting a serious threat to health or
safety to you, another person, or the public;
- Release of
information required by federal, state, or local law, or in
response to a court order, subpoena, or other discovery
request, as permitted by law.
- Release of
information requested by members of domestic or foreign
armed forces, to comply with the requirement of domestic or
foreign military command authorities;
- Release of
information for purposes of national security;
- Release of
information to health oversight agencies in connection with
legally authorized activities related to the investigation,
inspection, and licensure of health care providers; and
- Any other release of information required
In situations not outlined above, we will
ask you for written authorization before using or disclosing
any of your identifiable health information. If you choose
to sign an authorization, it can later be revoked to stop
future use and disclosure without your consent. Such a revocation
will not be effective, however, for any actions that we take
in reliance on your authorization prior to your revocation.
In addition, we will make reasonable efforts
when using, disclosing, or requesting patient health information
to limit information to the minimum necessary to accomplish
the intended purpose of the use, disclosure, or request. This
applies for all situations outlined above.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the
physical property of Advent Rehabilitation, the information contained within your
health record belongs to you. You have certain rights with
respect to that information, such as the right to inspect
and copy your medical information (with the exception of certain
psychotherapy notes); the right to request the restriction
of certain uses and disclosures of your information; the right
to obtain an accounting of disclosures of your health information
when such disclosures are made other than for treatment, payment,
related administrative or operating purposes as described
above, or to you, your personal representative, or to family
members or others involved in your medical care; and the right
to amend and request changes in the information contained
within your health record. These rights are explained in more
We may deny your request to amend or change
your medical record, if:
- The request is not in
- The request does not
include a reason to support the request;
- The information was
created by another health care provider;
- The information is
not part of the health information kept by or for us;
- The information is
not part of the health information you would be permitted to
inspect or copy; or
- Your health information is already accurate
If we exercise this right to deny your request,
you will receive a detailed explanation of the reasons for
the denial in writing. You have the right to complain about
this denial as outlined in the “Your Complaints”
section of this notice.
request for an accounting of disclosures of your information
from us must be in writing to Advent Rehabilitation’s
address, can be for a time no longer than six years, and may
not include a period before April 14, 2003.
The first disclosure list you request within a 12-month period
is free. For any additional request, we may charge you for
the cost of providing the list. We will notify you of that
charge in advance and provide you with the opportunity to
withdraw or modify your request after such notification.
You may request that we
not use or disclose your medical information except as
specifically authorized by you, when required by law, or in
emergency circumstances. We will consider your request,
but you should be aware that we are not legally
required to accept it and may, if we deem your request too
restrictive, elect not to treat you, or to disregard your
request in an emergency. If
we agree to your request, we will comply with it unless the
information is needed to provide you with emergency treatment.
To request restrictions, you must make your request in writing
at our address.
You have the right to inspect and obtain
a copy of your health record. Usually, this includes medical
and billing records, but does not include records such as
certain psychotherapy notes.
If you request copies of your health records,
the request must be in writing and there will be a charge
for such copies. This cost is directly related to the administrative
and copying charges associated with your request. If your
request for copies is, in your opinion, an emergency, please
let us know and we’ll work with you to meet these emergency
We may deny your request to inspect and
copy your medical information in certain very limited circumstances.
If you are denied access to your medical information, you
may request that the denial be reviewed. For information regarding
such a review, contact our office as stated below.
You also have the right to request that
we communicate with you about medical matters in certain ways
(home phone/cell phone) or at certain locations. Again, this
request must be in writing and should be specific as to how
and where you wish to be contacted. We do not need to know
the reasons for your request. We will comply with all reasonable
requests for us to communicate with you in a certain way.
We are required by law to maintain the privacy
of your health information, to provide you with this notice
of our legal duties and privacy practices, and to abide by
the terms of this notice, although we may change this notice
from time to time. We must also provide a process to address
any complaints that you have regarding privacy issues.
If you are concerned that we have violated
your privacy rights, our own policies as summarized in this
notice, or if you disagree with a decision we made about access
to your records, you may contact the person listed below.
You may also send a written complaint to the United States
Department of Health & Human Services. The person and
office listed below can provide you with the appropriate address
upon request. You will not suffer any retaliation for filing
a complaint. all complains must be submitted in writing.
Complaints may be filed by contacting Kevin Crossman in writing at 607 Dewey Ave. N.W., Suite 300, Grand
Rapids, MI 49504.
We are required by law to protect the privacy
of your information and to provide you with this notice about
our information practices. We are also required to abide by
the terms of this notice and to notify you if we are unable
to agree to a requested restriction you have made relative
to the use or disclosure of your information. In addition,
we are required to accommodate reasonable requests you make
regarding the communication of your health information by
alternate means or at alternative locations.
We may change our
policies or practices regarding the use of your health
information from time to time as explained in this notice. If
we make any changes, we will post the new notice in our
waiting areas, in our exam rooms, and on our website at www.adventrehab.com.
You have the
right to a written copy of this notice and can always request
a copy of our current notice at any time. In particular, you
have the right to a paper copy of this notice if you received
this notice electronically.
This notice applies to Advent Physical Therapy. (Advent Physical Therapy
also conducts its business under the name GRSportsCenter.)
If you have any questions regarding this notice or use or disclosures
of your health information, or wish to file a complaint
regarding our use or disclosure of your health information,
please contact Kevin Crossman, Compliance Officer at (616)