Welcome to Bronson LakeView Family Care Paw Paw (Suite A) · 2015. 1. 12. · If you need a referral or authorization from our office to see another kind of doctor, please call our

Welcome to Bronson LakeView Family Care Paw Paw (Suite A) Thank you for providing us with the opportunity to provide healthcare services for you and your family. This document contains the information you need about our practice. We look forward to building a partnership with you and look forward to serving as your healthcare provider location. Office Hours and Appointments Our office is open Monday through Friday, from 8 a.m. to 5 p.m. Select early morning and evening hours are available. Please call the office for an appointment. Your First Appointment Your first visit will include a review of your health history. We will mail you forms to complete and bring with you to your appointment. Or you may arrive 15 minutes before your appointment to complete the forms. You will also need to bring:

� Family health history forms � Photo identification of the insurance card holder � List of previous surgeries and illnesses � Medicine and over-the-counter items like vitamins (list or bottles) � Insurance card � Medical records from other doctors � Questions you may have

Canceling an Appointment We know things happen that make it hard to keep your appointment. Call our office the day before your appointment if you cannot make your scheduled appointment. If you don’t call and miss appointments, or arrive late several times, we may ask you to find another doctor. Young Patients Children under the age of 18 must have a parent or guardian with them. If a parent or guardian cannot attend, fill out a consent form or write a letter to give permission to treat. The child must bring the consent form or letter. Consent forms are at our office and online at bronsonhealth.com. Emergency & After-Hours Calls If you feel your emergency is a matter of life or death, call 911 or go to the nearest emergency department or urgent care center. If you have an urgent need after-hours, call our office. A doctor is on-call at all times to help with emergencies. Leave your name and phone number with our answering service. The doctor on-call will call you back. Bronson MyChart Bronson MyChart is a free and secure way to look at parts of your medical record on your computer. You can review prescriptions, send messages to your doctor or a member of our staff and schedule routine appointments. Ask our staff to set up your MyChart account.

Prescriptions Bring your medicine bottles with you when you come to the office. If you do not bring the medicine, bring a list of all the medicine you are taking. Be sure to ask for refill prescriptions while you are at the office. If you call later for refills, it may take up to two business days to get the prescription. We will send your prescriptions to your pharmacy electronically. Controlled narcotic substances and Attention Deficit Hyperactivity Disorder (ADHD or ADD) medicines still need a paper prescription. This can either be sent to you in the mail or you can pick up in our office. Be sure to ask for refill prescriptions while you are at the office so you do not run out of medicine. We do not give prescriptions for new medicine, antibiotics or pain medicine over the phone. We need to see you in the office before ordering these medicines. Referrals If you need a referral or authorization from our office to see another kind of doctor, please call our office at least one week before your appointment. We will let your insurance company know why you need to have this appointment. This will help you get the best benefit from your insurance plan. If you do not get approval before your appointment, you may have to pay for the visit yourself. We cannot authorize visits that have already happened. Fees & Insurance Payment for your healthcare services from our doctors may be covered by your medical insurance. To find out if we participate with your insurance company, visit bronsonhealth.com (select Find a Doctor). For every appointment, you will need to bring your insurance card(s). We will send claims for services we do in our office to your insurance company. You may get different bills for lab, X-ray and other testing procedures. Billing for these services will be sent to you or your insurance company. Your insurance company can explain what services will be paid for under your insurance plan. Co-payments are to be paid at the time of your visit. We accept cash, checks and most major credit cards. If you do not have health insurance coverage, ask our staff about our financial assistance program. If there is an outstanding balance, a billing statement will be sent to you. We also reserve the right to charge a nominal fee for copies of your medical records and completion of medical forms. If you have difficulty paying a bill or need financial assistance, or have questions about fees or insurance, please contact our billing department at (269) 341-6117, Monday through Friday, 8 a.m. to 4:30 p.m. Bronson LakeView Family Care Paw Paw (Suite A) 451 Health Parkway, Suite A Paw Paw, MI 49079 (269) 657-2550 For more information, visit our practice page on bronsonhealth.com

Thank you for choosing us for your healthcare needs. Enclosed are a few more pieces of information to help prepare you for your visit. Below is a list of paperwork for you to complete and bring with you to your appointment.

FORMS

q Registration Form q Financial Policy q Bronson Lakeview Medical Practices Authorization to Treat (if applicable) q Parental Minor Consent Form (if applicable) q Advance Directive q HIPAA – Notice of Privacy Practices q Diagnostic Use Authorization Form q Family Health History Form q Medical records From Other Doctors

Consent For Release of Information

You will also need to complete the enclosed authorization for release of information. You will need to mail it to your previous doctor as soon as possible. This will allow us to obtain your medical records for your first visit.

Appointment Billing

Your healthcare provider feels it is important for your health to have a complete physical exam. Please be aware that many insurance companies do not cover routine or preventative services. This visit may be billed as a routine service and submitted to your insurance company as a routine service.

Testing

If you have an early morning appointment, you may want to fast for 12 hours (nothing to eat or drink except water) before your appointment. This way, if your healthcare provider would like you to have fasting lab work done, you may do that while you are here and save yourself an extra trip. If you are not fasting or have a later morning or afternoon appointment, you can return to the lab for your blood work at another time.

An EKG may be performed during your visit, please do not use any body lotions or creams on the day of your appointment.

If you have any questions, please feel free to contact our office at 269-657-2550.

We look forward to seeing you at your appointment.

Bronson Lakeview Family Care- Paw Paw Suite A

Revised 8/2011 Page 1 of 2

o 319 W Delaware, Decatur, MI 49045 • (269) 423-7028 o 52375 N Main St, Mattawan, MI 49071 • (269) 668-3348 o 451 Health Parkway, Suite A, Paw Paw, MI 49079 • (269) 657-2550 o Surgery - 404 Hazen, Suite 101, Paw Paw, MI 49079 • (269) 657-4407 o 451 Health Parkway, Suite B, Paw Paw, MI 49079 • (269) 655-3065

Patient Name ________________Date of Birth ________ Date _______________

Marital status: ___ Married ___ Single ___ Widowed ___ Divorced

Do you see other specialists? If yes, then who? __________________________________________________

Race/Ethnicity: ___ Hispanic/Latino ___ White ___ Black/African American ___ Asian

___ Native Hawaiian/Other Pacific Islander ___ American Indian/Alaska Native ___ Other

Preferred Language:_______________________________________________________________________

NEW HEALTH HISTORY FORM (ADULT)

SURGERIES:

IMMUNIZATIONS (list the last time you had): Tetanus/Date: _________________________ TB test Pneumovax Flu shot MMR Hepatitis B Shingles

MEDICATIONS (you are currently taking from all providers): *only needs completed at first new patient visit.

ALLERGIES (list allergies to medicines): _________________________ Latex allergy Y N Have you been hospitalized in the last 3 years? Y N

MEDICAL HISTORY

Have you ever had? Y N Have you had in last year? Y N Have you had in last year? Y N Cataracts Dizzy spells Extreme fatigue Glaucoma Numb arm/leg Night sweats Allergies/sinus Frequent headaches Frequent fevers Anemia Fainting Frequent sore throats Asthma Hearing loss Frequent earaches Pneumonia Vision loss Frequent bronchitis Hiatal hernia Chest pain Joint pain Stomach ulcers Shortness of breath Swollen ankles Thyroid disease Wheezing Foot problems High cholesterol Cough Recurrent rashes Diabetes Loss of appetite Moles (new size/color) High blood pressure Indigestion Dental exam Heart murmur Heartburn Eye exam Irregular pulse Frequent diarrhea Palpitations Frequent constipation Childhood Diseases

(check if you had): Heart disease Bloody stools Head injury Tarry stools Chicken pox Seizures Rectal itching Tuberculosis Depression/anxiety Urinary infections Mumps Kidney disease/stones Blood in urine Rubella Colon polyps/colitis Frequent urination Rheumatic fever Cancer Sudden weight loss (> 10 lbs) Polio Osteoporosis

Patient Name _________ Date of Birth ____________ Date_____________________

Revised 8/2011 Page 2 of 2

MEN: Problems with urination? Y N Prostate trouble? Y N Last prostate check & blood test ___________________

Do you perform testicular exams? Y N Discharge from penis? Y N Impotence? Y N

Circle if you have had: Hernia Hepatitis Herpes HIV Transfusion WOMEN: Total number of times pregnant___________ Are you nursing? Y N Number of living children________________ Any abnormal pap smears? Y N Number of miscarriages/abortions_________ Any breast disease? Y N Date of last mammogram________________ First day of your last period______________ Date of your last pap test________________ Circle if you have had: Herpes Hepatitis Frequent yeast Transfusion HIV SOCIAL HISTORY: Occupation ______________________________________________________ Do you wear a seatbelt? Y N Do you drink coffee/tea/soda? Y N How many cups/day Do you drink alcohol? Y N How many drinks/day Do you smoke/chew/use tobacco? Y N How many packs/day Have you used street drugs? Y N Which ones __________________________________________ Do you wear sunscreen? Y N FAMILY HISTORY:

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Allergy/sinus Asthma Breast cancer Cancer (other) Colon polyps/colitis Diabetes Heart disease/attacks High blood pressure High cholesterol Thyroid disease Stroke Depression/anxiety Alcohol/drug use Kidney disease Tuberculosis Osteoporosis This is my important medical history. The doctor will use this information to make medical decisions about me. I am responsible to tell my doctor about my medical history on this form. Patient Signature Date Provider’s Signature Date

Page 1 of 2

LakeView

Request for Access or Authorization for Use and Disclosure of Protected Health Information

Patient Name: _____________________________________________________________________ Last First MI Date of Birth: _________________________________ Month Day Year

I give permission to Bronson Medical Practices to use or disclose my protected health information indicated below to

Physician to release records:

Name_________________________________

Address:_______________________________

__

Phone __

Fax __

Physician/Person to receive records:

Bronson Lakeview Family Care Paw Paw

451 Health Pkwy Suite A

Paw Paw, MI 49079

Phone: (269) 657-2550

Fax: (269) 657-2285 Information to be released:

(Please check boxes that apply)

ð Discharge Summary

ð History and Physical Exam

ð Progress Notes

ð Lab Reports

ð X-Ray Reports

ð Medication Records

ð Detailed Bill

Other (specify content and dates) ______________________________________________________

Purpose of Disclosure:

ð Changing doctors

ð Consultation

ð Insurance or Workers’ Compensation

ð School

ð Research

ð At request of individual

ð Legal (specify) _______________________________________________________________

ð Other (specify) _______________________________________________________________

ð For my own use

Page 2 of 2

I authorize the release of health information, contained in my medical records including:

• Information regarding communicable diseases and infections, as defined by statue and Michigan

Department of Health rules, which include venereal disease, Tuberculosis, Hepatitis A, B, C,

Human Immunodeficiency Virus (HIV), HIV testing.

• Acquired Immunodeficiency Syndrome (AIDS) and AIDS related complex (ARC).

• Alcohol and drug abuse treatment information protected under the regulations in CFR 42, Part 2.

• Mental health treatment records, psychological services and social services information including

communications made by me to a social worker, therapist, or psychologist.

Acknowledgement of Understanding:

• I understand this authorization will expire in one year from date signed.

• I can cancel this authorization at any time by writing to Bronson Medical Group.

• It will take effect on the date notified, except if action has already been taken.

• I understand that if I release my medical record to a person or provider, they can release my

medical record. I know I need to check with them about their privacy rules.

• I will get an abstract of my medical record unless I ask for the complete record.

• No conditions will be placed on me if I sign this form.

Michigan law says I may have to pay for:

• Copies of my record

• Inspection of my record

• Written summary of findings

Bronson Medical Practices will not benefit from disclosing this information.

____________________________________________________ ___________________________

Signature of Patient Date

____________________________________________________ ___________________________

Parent or Personal Representative Date

Affix Patient Label

*9004286*

9004286 (11/13) Intranet Patient Demographics Page 1 of 4

(Bronson Medical Practices)

Patient Demographics Demographics – Patient Information

Last Name: _____________________ First Name: _________________ Middle Name: _____________

SSN: ________/_______/_______ Sex: M / F / U Birth Date: ____/____/____

Address: ____________________________ Home Phone: __________________

____________________________ Work Phone: ___________________

City: _______________________________ Cell Phone: ____________________

State: __________ Zip: ______ E-Mail Address: ________________

Other Communication

Allowed Communication: ____ Do Not Contact ____ Mail ____ Phone ______Text

____E –mail ____ MyChart Signup

Needs Interpreter? Y/ N Language: ________________________

Marital Status: __________________ Religion: _________________________

Ethnicity: Hispanic/ Not Hispanic

Race: ______________

PCP Care Provider Information

Primary Care Physician: _________________________________________________________________

Emergency Contact – In Case of Emergency, who to contact

Last Name: _______________________ First Name: __________________ Middle Name: ___________

Relation to Patient: ________________________

Home Phone: __________________ Work Phone: _______________ Cell Phone: _________________

Patient Employment

Employer: ___________________________ Employment Status: _____ Not Employed

Affix Patient Label

Patient Name:____________________ DOB:_________________



Employer Address: ____________________ Employment date: _____________________

City: _________________________ Employee ID: __________________________________

State: ________ Zip: __________ Occupation:_____________________________________

Phone: _______________________ Fax: __________________________________________

Religious Affiliation

Church: ______________________________________________________________

Guarantor Accounts – If patient is over 18 years of age, see patient information

Last Name: _______________________ First Name: __________________ Middle Name:__________

Account Type: Patient/Family / Workers Comp / Auto SSN: ________/_______/_______

Sex: M/F/U Birth Date: ____/____/____ Relation to Patient: ________________________

Address: _________________________ City: _________________________

_________________________ State: __________ Zip: ______

Home Phone: __________________

Guarantor Employer: ___________________ Employ. Status: Full Time / Part Time

Address: _____________________________ City: _________________________

_____________________________ State: __________ Zip: ______

Phone: __________________

Primary Coverage

Name of Coverage: _______________________________________________________________

Member Relationship to Subscriber: __________________________________________________

Affix Patient Label

Patient Name:____________________ DOB:_________________



Insurance ID: ________________________ Member Effective Date: ________________________

Group Number: ______________________ Group Name: ________________________________

Authorization Phone: ________________________________

Covered Through: Employment / Retirement Employer size: _________________________

Subscriber Name: ___________________ SSN: ________/_______/_______ Sex: M/ F / U

Birth Date: ____/____/____

Subscribers Address_____________________________ City: ___________________________

_____________________________ State: __________ Zip: __________

Subscriber Phone: ____________________

Secondary Coverage

Name of Coverage: ________________________________________________________________

Member Relationship to Subscriber: ___________________________________________________

Insurance ID: ________________________ Member Effective Date: ________________________

Group Number: ______________________ Group Name: _________________________________

Authorization Phone: ___________________________

Covered Through: Employment / Retirement Employer size: __________________________

Subscriber Name: ___________________ SSN: ________/_______/_______ Sex: M/ F / U

Birth Date: ____/____/____

Subscribers Address_____________________________ City: _____________________________

_____________________________ State: __________ Zip: ______

Subscriber Phone: _____________________________

Affix Patient Label

Patient Name:____________________ DOB:_________________



Visit Specific Information

Reason for Visit: ____________________________________________

Accident Related: Y / N If Yes, Fill out Accident Information below

Accident Date: ____________________ Accident Time: ___________________

Accident Type: _____________________ Place of Injury: Home / Work / Other

Body Part Injured: __________________ Accident Description: ________________________

______________________________________________________________________________

Referring Physician (if applicable):________________________________________________________

MRN_________________________________________________

CSN__________________________________________________

I.01-RH Bronson LakeView Medical Practices Financial Policy

Bronson Lakeview Practices are committed to giving you the best possible medical care. If you have special needs, we are here to work with you. The following information is about payment for professional services. • Our office participates with many insurance plans. If you are a member of one of these

plans, our business office will submit a claim for services. If we are not a contracted provider for your insurance, we will bill the insurance as a courtesy. You must assign benefits to the practice. This means payment from the insurance plan will come directly to the practice. It is your responsibility to: • Give us your current insurance and billing information • Tell us your Social Security number • Bring your insurance card to each visit • Pay your co-pay at each visit • Pay any balance not covered by your insurance

• We will send you a monthly statement if you owe us money. The statements will show what you should pay and what your insurance should pay. When you get the statement, you are expected to pay what you owe in 30 days. Any balances over 90 days may be sent to a collection agency.

• You agree, in order for us to service our account or to collect any amounts you may owe,

we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

• Payment for professional services can be made with cash, check or credit card.

You will get a separate bill for lab, x-ray, pathology and other hospital services. You will be billed $25.00 for any returned checks. You can pay this charge by credit card, money order or in cash.

• Specialist Authorizations: You must get any required authorizations for treatment

before your visit. If you do not have the authorization, your visit may be rescheduled. You may be responsible for paying the bill.

• Primary Care Authorizations: If your primary care provider is not a Bronson LakeView

Family Care provider, you must get the required authorizations from your primary care provider (PCP) or health plan before your visit. If you do not have the authorization, you may be responsible for paying the bill.

• Workers’ Compensation: If your claim has been accepted and services approved, your

claim will be handled directly by your Workers’ Comp carrier. You will not be charged for services. Your recovery and return to work takes a partnership with you, your case manager and us. If your claim is denied, you may be responsible for the bill.

• If the patient is a minor (18 years or younger), the parent or guardian must sign this

form. The parent, guardian or unaccompanied minor is responsible for any payment due at the time of service. Please bring the authorization and insurance card to each visit.

• Some services, such as preventive services, may not be covered under your insurance plan or Medicare. You are responsible to pay any balance not covered by your insurance plan.

• If you have questions about your insurance, we are happy to help you. Specific coverage

issues should be directed to your insurance company member services department. The number is on the insurance card.

• We may charge you $25.00 if you:

o Cancel within 24 hours of your appointment o Do not show up for your appointment time

Our practice believes that a good provider and patient relationship is based upon understanding and good communication. If you have questions about financial arrangements and payment plans please direct them to the provider’s office. We are here to help you. Assignment This practice may release any medical information needed to decide a claim for payment to any third party payor, insurance company or government agency. All payments for medical services for myself or dependents should go to Bronson. I agree to pay for any charges not covered by my insurance. _________________________________________ __________________ Signature of Responsible Party Patient’s Date of Birth ______________________________________________________ Date Review/Revised 4/07, 4/09, 5/09, 5/10, 7/10, 11/10, 3/11, 10/11, 3/12, 11/12

Patient Name: _______________________________

Date of Birth: ________________________________

Adult Consent to Treat

I, ____________________________________________, give permission to the staff of Bronson

LakeView Practices to give me medical treatment. I agree to tell Bronson LakeView Medical

Practices if I have any concerns about my medical treatment at the time of treatment.

Signature Date

Print

*9004405*

Name: ________________________ Date of Birth:_______________

9004405 (8/13) Intranet Authorization to Share Medical Information Page 1 of 1 WH20-5HT

Affix Patient Label

Authorization to Share Medical Information

I authorize Bronson Healthcare Group to share my:

Personal and/or demographic information

Medical information – excluding _____________________________________________________

Billing/financial/insurance information

All information

To the following individuals:

_______________________________ _______________________ __________________________

Name Phone Number Relationship to Me

_______________________________ _______________________ __________________________


_______________________________ _______________________ __________________________


_______________________________ _______________________ __________________________


-OR-

I do not authorize Bronson Healthcare Group to release any of my medical information to anyone, with the

exception of coordination of benefits (i.e., insurance) or continuation of care (i.e., referrals).

This authorization will remain in effect until revoked in writing by the above listed patient.

______________________________________________________ ______________________________

Signature Date

*9004491*

9004491 (7/13)WH-20

Advanced Directive Questionnaire

Adult Use Only

Affix Patient Label

Name______________________ Date of Birth__________

Bronson Physician Practices

Advance Directive

Questionnaire

1. Do you have an advance directive?

If yes-I was instructed to provide a copy Yes o No oto the office for placement in my chart.

2. If you do not have an advance directive, would you like further information?

If yes-An information packet was Yes o No oprovided to me including:

l Designation of Patient Advocate Form

l Advance Directive Information for Patients (Q&A)

___________________________________________ _________________________________

Print Name DOB

___________________________________________ _________________________________

Patient Signature Date

Page 1 of 1

9002795-E (07/14) Intranet/Internet Bronson Healthcare Group Notice of Privacy Practice Page 1 of 7 Equivalent to 9002833-S

NOTICE OF PRIVACY PRACTICES 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.

I. Who We Are

This Notice describes the privacy practices of Bronson Healthcare Group, Inc., and each of its subsidiaries, including, but not limited to, Bronson Methodist Hospital, Bronson Battle Creek Hospital, and Bronson LakeView Hospital (“we” or “us”), including:

All healthcare professionals allowed to enter or access information in your medical record.

All employees and physicians and other health care professionals on the Medical Staff when they provide services in our facilities with access to your medical or billing records or health information about you (“Protected Health Information”).

Any student or volunteer authorized to help you while you are a patient.

Bronson has expanded the use of its electronic medical record system to affiliated partners. A list of affiliated partners may be found on the Bronson web page.

II. Our Privacy Obligations

We understand that your health information is personal and we are committed to protecting your privacy. In addition, we are required by law to maintain the privacy of your Protected Health Information, or “PHI”, to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information, and to notify you in the event of a breach of your unsecured Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. Permissible Uses and Disclosures Without Your Written Authorization

In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your Protected Health Information. However, unless the Protected Health Information is Highly Confidential Information (as defined in Section IV.D below) and the applicable law regulating such information imposes special restrictions on us, we may use and disclose your Protected Health Information without your written authorization for the following purposes:


Treatment. We use and disclose your Protected Health Information to provide treatment and other services to you. We may use and disclose health information to contact you for an appointment reminder, to tell you about health related services or recommend possible treatment options or alternatives that may be of interest to you, to help prepare a research project, to contact you to ask whether you want to participate in a study.

Doctors and other providers who may treat you at places other than Bronson need access to the most complete information possible in order to make treatment decisions about your care. These providers are able to access your electronic and paper records from Bronson for this purpose. For example they may view your medications and test results. If you must leave Bronson for care, your new provider may view your Bronson treatment records. Likewise, when a provider has referred you to Bronson for treatment, they are able to access your electronic record to provide follow up medical care.

Payment. We may use and disclose your Protected Health Information to obtain payment for health care services that we provide to you; for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of your health care (“Your Payor”) to verify that Your Payor will pay for the health care. We may also disclose Protected Health Information to your other health care providers when such Protected Health Information is required for them to receive payment for services they render to you.

Health Care Operations. We may use and disclose your Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality of our services and health care professionals.

Fundraising Communications. We may use certain information (name, address, telephone number, email address, date(s) of service, age, gender and insurance status) to contact you in the future to raise money for our institutionally – related foundation, the Bronson Health Foundation. The money raised will be used to expand and enhance the services and programs that we provide to the community. If you do not want to receive any fundraising requests in the future, you may contact the Bronson Health Foundation at 269-341-8100.

Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if: (1) we obtain your agreement or provide you with the opportunity to object to the disclosure and you do not object; or (2) we reasonably infer that you do not object to the disclosure.


If you are not present for or unavailable prior to a disclosure (e.g., when we receive a telephone call from a family member or other caregiver), we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information under such circumstances, we would disclose only information that is directly relevant to the person’s involvement with your care.

As Required by Law. We may use and disclose your Protected Health Information when required to do so by any applicable federal, state or local law.

Public Health Activities. We may disclose your Protected Health Information: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to a government authority authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

Victims of Abuse, Neglect or Domestic Violence. We may disclose your Protected Health Information if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority authorized by law to receive reports of such abuse, neglect, or domestic violence.

Health Oversight Activities. We may disclose your Protected Health Information to an agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Officials. We may disclose your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

Decedents. We may disclose your Protected Health Information to a coroner or medical examiner as authorized by law.

Organ and Tissue Procurement. We may disclose your Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.


Clinical Trials and Other Research Activities. We may use and disclose your Protected Health Information for research purposes pursuant to a valid authorization from you or when an institutional review board or privacy board has waived the authorization requirement. Under certain circumstances, your Protected Health Information may be disclosed without your authorization to researchers preparing to conduct a research project, for research or decedents or as part of a data set that omits your name and other information that can directly identify you.

Health or Safety. We may use or disclose your Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

Specialized Government Functions. We may use and disclose your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

Workers’ Compensation. We may disclose your Protected Health Information as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.

IV. Uses and Disclosures Requiring Your Written Authorization

For any purpose other than the ones described above in Section III, we only use or disclose your Protected Health Information when you give us your written authorization.

A. Marketing. We must obtain your written authorization prior to using your Protected Health Information for purposes that are marketing under the HIPAA privacy rules. For example, we will not accept any payments from other organizations or individuals in exchange for making communications to you about treatments, therapies, health care providers, settings of care, case management, care coordination, products or services unless you have given us your authorization to do so or the communication is permitted by law.

We may provide refill reminders or communicate with you about a drug or biologic that is currently prescribed to you so long as any payment we receive for making the communication is reasonably related to our cost of making the communication. In addition, we may market to you in a face-to-face encounter and give you promotional gifts of nominal value without obtaining your written authorization.

B. Sale of Protected Health Information. We will not make any disclosure of Protected Health Information that is a sale of Protected Health Information without your written authorization.

C. Psychotherapy Notes. We will not use or disclose psychotherapy notes about you without your authorization except for use by the mental health professional who


created the notes to provide treatment to you, for our mental health training programs or to defend ourselves in a legal action or other proceeding brought by you.

D. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain health information about you (“Highly Confidential Information”), including Alcohol and Drug Abuse Treatment Program records and other health information that is given special privacy protection under state or federal laws other than HIPAA. However, in order for us to disclose any Highly Confidential Information for a purpose other than those permitted by law, we must obtain your authorization

E. Revocation of Your Authorization. You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below.

V. Your Individual Rights

A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your Protected Health Information, you may contact our Privacy Office. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.

B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction unless the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service for which you have paid us out of pocket in full. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.

C. Right to Receive Communications by Alternative Means or at Alternative Locations. You may request, and we will accommodate, any reasonable written request for you to receive your Protected Health Information by alternative means of communication or at alternative locations.


D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we may charge you a reasonable copy fee.

E. Right to Amend Your Records. You have the right to request that we amend your Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from Health Information Management (Medical Records). We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

F. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years. If you request an accounting more than once during a twelve (12) month period, we may charge you a reasonable fee for the accounting statement.

G. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective on July 28, 2014.

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all your Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our waiting room and on our Internet site at www.bronsonhealth.com. You also may obtain any new notice by contacting the Privacy Office.

VII. Privacy Office

You may contact the Privacy Office at: 269-341-8590 or at: [email protected]

Mail may be addressed to:

Bronson Privacy Office

601 John Street, Box 50

Kalamazoo, MI 49007


*9002795*

Please sign below that you have received Bronson Healthcare Group’s Notice of Privacy Practices effective July 28, 2014.

Print Name:

________________________________________________________________________

Date of Birth:_________________________

Signature:

________________________________________________________________________

Date: ___________________________

Relationship if other than Patient: ___________________________________

Witnessed by: ________________________________ Date/Time:___________

Action:

_____ Provided, patient declines to sign

_____ Patient indicates previously signed

_____ Other: ____________________

Due to various insurance requirements, it is necessary for us to inform you of where your diagnostic test will be sent.

The tests may or may not be covered by your insurance plan. If you have any questions about your insurance coverage, please contact your insurance company prior to having these tests performed.

I acknowledge that all diagnostic specimens obtained in our office (ex: laboratory, pathology, cytology etc.) will be sent to Bronson Hospitals for processing.

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Documents

Welcome to Bronson LakeView Family Care Paw Paw (Suite A) · 2015. 1. 12. · If you need a referral or authorization from our office to see another kind of doctor, please call our