Notice of Privacy Policy

FOR THE OFFICES OF JACOB KALO, M.D.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. – PLEASE REVIEW CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: Treatment, Payment, and other health care operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
• Health care operations includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be accreditation, certification, licensing, or credentialing activities.

Other uses and disclosures include, but are not limited to the following:

• To remind you of an appointment either by mail or through a phone call.
• To inform you of potential treatment alternatives or options.
• To inform you of health related benefits or services that may be of interest to you.

I. Uses and Disclosures beyond treatment, payment, and Health Care Operations Permitted without Authorization or Opportunity to object.

Federal privacy rules allows us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:

• When legally required we will disclose your protected health information when we are required to do so by and Federal, State, or Local law.

When there are risks to Public Health we may disclose your protected health information for the following reasons ( but not limited to):

• To prevent, control, or report disease, injury or disability as permitted by law.
• To report vital events such as 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 & product defects, enable product recalls, and repairs/replacements to the FDA.
• To notify a person who has been exposed to a communicable disease or who may be at risk of 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.
• To report Abuse, Neglect, or Domestic Violence
• To conduct Health Oversight Activities we may disclose your protected health information for activities such as an audit or criminal investigation. We will not disclose your information if you are the subject of and investigation and your health information is not directly related to your receipt of health care or public benefits.
• In connection with Judicial and Administrative Proceedings we may disclose your protected health information in response to a court order.

For Law Enforcement Purposes we may disclose your protected health information to a law enforcement official for the following (but not limited to):

• As required by law for reporting certain types of wounds or other physical injuries.
• When you are a victim of a crime.
• In an emergency in order to report or prevent a crime.
• To help locate a missing person.
• In the Event of a serious threat to Health or Safety we may disclose your protected health information if we believe, in good faith, that it is necessary to prevent or lessen a serious and imminent threat to your health or safety.
• For Worker’s Compensation we may release your health information to comply with worker’s compensation laws or programs.

II. Uses and Disclosures Permitted without Authorization but With Opportunity to Object

We may disclose your protected health information 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 the trying to locate or notify family members or others involved in your care concerning your location, condition, or death.

You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or through our professional judgement, that it is in your best interests for us to make this disclosure we will do so with your information as described.

III. Uses and Disclosures which you Authorize

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

IV. Your Rights

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. -You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. Although we will not require an explanation for your request- we will require that your request be done so in writing with an explanation as to how we should handle your particular situation.
• The right to inspect and copy your protected health information.You must submit a written request to Dr. Jacob Kalo. If you request a copy of your information, we may charge a fee for the costs of copying, mailing, or other costs incurred by us in complying with your request
• The right to amend your protected information
• The right to receive an accounting of disclosures of protected health information. -This refers to all disclosures for the purposes other than treatment, payment, or other health care operations as described in this Notice of Privacy Practices. We are NOT REQUIRED to account for disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends and family members involved in your care. THIS REQUEST FOR ACCOUNTING MUST BE MADE IN WRITING TO DR. JACOB KALO. 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. ACCOUNT REQUESTS MAY NOT BE MADE FOR PERIODS OF TIME IN EXCESS OF SIX YEARS. There will be a fee for this request.
• The right to obtain a paper copy of this notice from us upon request.
• We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 16, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice of provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You may complain to the practice by contacting either Dr. Jacob Kalo or the Privacy Officer verbally or in writing using the contact information below or you may contact the Secretary of Health and Human services.

The practices contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Officer. Information regarding matters covered in this Notice can be requested by contacting Dr. Kalo or the Privacy officer. Complaints against the practice can be mailed to the following:

Jacob Kalo, M.D.
15650 E. 8 Mile Rd
Detroit, MI 48205
ATTN: Privacy Officer
The Privacy officer can be contacted by phone at (313) 526-3600

Acknowledgment of Privacy Practices:

I acknowledge that I have received the attached Notice of Privacy Practices.

________________________________________
Patient or Personal Representative Signature

____________________
Date

If Personal Representative’s signature appears above, please describe Personal

Representative’s relationship to the patient: _____________________________.

Patient Refuses to Sign ___________.

Witness _________________________________.