Privacy Policy

Midwest Sports Medicine Institute

Notice of Privacy Practices

Please review this documentation carefully. This notice describes how your medical information may be used and disclosed by Midwest Sports Medicine Institute (MSMI). It further details how you or your personal representative may gain access to this information.

The Health Insurance and Portability and Accountability Act (HIPPA) of 1996 require all health care providers to provide all of there patients a Notice of Privacy Practices (Notice). MSMI uses your Protected Health Information to carry out treatment, obtaining payment for treatment and conducting health care operations and other purposes permitted or required by law. This notice describes how MSMI may use and disclose this Protected Health Information (PHI), your rights to access this information and to control its use and disclosure.

PHI includes any written or verbal health information, including demographic data which may be used to identify you. This information is created or received by your health care provider and it relates to your past, present or future physical or mental health condition.

For the purposes described in the Notice, disclosures of your PHI may be made by electronic, facsimile, verbal, written or any other means permitted by HIPPA Privacy Regulations or State law. The quantity of information used or disclosed will be limited to the minimum required for each use or disclosure.

• Uses and Disclosures of PHI
• Treatment - MSMI will use and disclose your PHI to provide manage or coordinate your health care and any related services. This may include other physicians who may be treating you or consulting with your other physicians. Other examples may include a pharmacy for prescriptions, a laboratory or radiology provider for testing, Physical Therapists for complimentary treatment or a home care agency or hospice for in home care.
• Payment – MSMI will use your PHI to obtain payment for the services we provide. Examples include disclosure of PHI to your insurer to determine eligibility for benefits, coverage if services or approval prior to a procedure. PHI may be disclosed for the purpose of determination of medical necessity and utilizations and review of the services provided as required by your insurer.
• Operations – MSMI may use or disclose your PHI to improve the practice and provide the highest level of quality care to our patients. Examples include supervised training for employees and other individuals, continuous quality improvement activities, employee reviews, compliance reviews as required by governmental agencies, accreditation, certification and credentialing activities and management and administrative activities to maintain the business. A health plan or insurer may require MSMI to disclose PHI for their health care operations.
• Other Uses and Disclosures – To ensure the optimal operation of the practice MSMI may disclose PHI to remind you of an appointment or schedule one with another health care provider, inform you of alternative services and treatment options that may be of interest or benefits to you.
• Uses and Discloser Beyond Treatment, Payment and Health Care Operation Permitted Without Authorization or Opportunity to Object
• Legal – MSMI will comply with all Local, State and Federal Laws
• Risks to Public Health – MSMI may disclose your PHI as it benefits the public welfare. Examples include reporting to injuries or disability and diseases as permitted by law; to assist in public health surveillance, investigations or interventions as required by law; report drug and medical

device information as required by the FDA, communicable disease exposure notification as

authorized by law; report to an employer information about an employee that is legally

permitted or required.

C. Child Abuse – As required by law.

• Elder Abuse – As required by law.
• Domestic Violence – As authorized by law or when the patient agrees to the disclosure.
• Health Care Oversight – Your PHI may be disclosed to a health oversight agency for audits; administrative, civil or criminal investigation; inspections; licensure or disciplinary actions and any other health care oversight necessary by law.
• Judicial and Administrative Proceedings – As required by law.
• Law Enforcement - As required by law and court orders. We will aid in the law enforcement agencies to identify or locate a suspect, fugitive, material witness or missing person. We will notify them if you are a crime victim; including a homicide victim.
• To Protect Your Health from a Serious Threat – We will act in good faith consistent with the law and ethical standards of conduct to prevent or lessen a serious threat to you the public.
• Specific Government Functions – We will cooperate with the government to facilitate specific functions as they may pertain to the military and veteran’s activities and other federal agencies with proper authorization.
• Workman’s Compensation – As required by law.
• Uses and Disclosures Permitted Without Authorization but with the opportunity to Object.

PHI may be disclosed to a family member or close friend as long as it is relative to the individual’s involvement in your care. You may object to disclosure. If you do not we will use our best professional judgment to disclose PHI only when we believe it services your best interest.

• Uses and Disclosures Which You Authorize.

PHI will not be disclosed without your authorization except as noted above.

• Your Rights
• You may inspect and copy your PHI. You must submit a written notice to the privacy officer. We may charge a fee to cover the costs of copying, mailing and handling. A request may be denied if in our professional judgment it will endanger your life or another’s safety. You may appeal this decision. Federal law does not allow your access to psychotherapy notes; information compiled for an administrative, civil or criminal action.
• The right to request a restriction on uses and disclosures of your PHI. You may ask us not to disclose certain parts of your PHI for the purpose of treatment, payment or health care operations or to certain family members. This request must state the specific restriction requested and to whom it applies. We are not bound to honor this request. If we agree to a request we may terminate it if in our professional judgment it is in your best interests.
• The right to request to receive confidential communications from us by alternative means or at an alternative location. We will attempt to accommodate reasonable requests. You will be responsible for an additional expense to MSMI.
• The right to have your physicians amends your PHI. You may request an amendment to your PHI as long as we maintain it. In your written request you have the right to file a statement of disagreement with us. If we prepare a rebuttal to your statement you will be provided a copy of it.
• The right to receive an accounting. You may request an accounting in certain disclosure of your PHI made by MSMI. This does not apply to disclosures for treatment, payment or health care operations; not for disclosures you have requested or authorized; to friends or family members involved in your care; or certain other disclosures we are permitted without your authorization. We are not required to comply with requests for periods in excess of 6 years. Request must specify a specific time frame. We will be responsible for all copying, mailing and handling fees.
• The right to obtain a paper copy of this notice. Upon request we will provide a separate copy of this notice. Multiple requests will not be honored unless a valid written explanation is provided.
• All requests are to be in writing.
• Our Duty

Federal law requires MSMI to maintain the privacy of your PHI and to provide you this Notice of our duties and our privacy practice. We will be abiding by these terms. We reserve the right to amend this Notice from time to time as the practice of medicine and technology evolves. Revisions will be provided at the time of the next service or through the mail.

• Complaints

You have the right to express your complaints to MSMI or to the Secretary of Health and Human Services if you feel that your privacy rights have been violated. You will not be retaliated against.

Effective Date

July 23, 2007