Effective: April 2003

Updated January 2012

NOTICE OF PRIVACY PRACTICES

Michigan Otolaryngology Surgery Associates, P.C.                      

And MOSA-Audiology  (both referred to as MOSA)                

5333 McAuley Drive, Suite 2017                                                      

Ypsilanti, MI   48197                                                                       

734-434-3200 or 800-851-6672                                                        

FAX 734-434-3209            

Thomas A. Weimert, M.D .

Ronald S. Bogdasarian, M.D.

Laurence Ho, M.D

Paul T. Hoff, M.D.

Michelle Mardegian, PA-C

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.

                We respect our legal obligation to keep health information that identifies you private.  We are obligated by law to give you notice of our privacy practices.  This Notice describes how we protect your health information and what rights you have regarding information.  If you have any questions about his Notice, please notify the office contact person shown above.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

            The most common reason why we use or disclose your health information is for treatment, payment or health care operations.  Examples of how we use or disclose information for treatment purposes are:  setting up an appointment for you; performing a physical examination; performing diagnostic tests; prescribing medications and faxing them to be filled; obtaining hearing aids for you through hearing aid providers; referring you to another doctor or clinic for additional or specialist services; getting copies of your health information from another professional that you may have seen before us; or faxing information to and from the main office to our satellite offices for treatment.  Examples of how we use or disclose your health information for payment purposes are: asking you about your health insurance coverage or other sources of payment; preparing and sending bills or claims; discussing claim information with your insurance carrier; and collecting unpaid amounts (either ourselves or through a collection agency or attorney).  “Health care operations” means those administrative and managerial functions that we have to do in order to run our office.  Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

                We may release medical information about you to a friend, family member or member of the clergy who is involved in your medical care, if listed in your medical records, unless you tell us not to.

                We routinely use your health information inside our office for these purposes without any special permission.  If we need to disclose your health information outside of our office for these reasons, we will ask you for special written permission.

                We will ask for special written permission in the following situations: record copy service, attorney request and any person not listed in your records.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

                In some limited situations, the law allows or requires us to use or disclose your health information without your permission.  Not all of these situations will apply to us; some may never come up at our office at all.  Such uses or disclosures are:

• When a state or federal law mandates that certain health information be reported for a specific purpose;
• For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from federal Food and Drug Administration regarding drugs or medical devices;
• Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
• Uses and disclosures for health oversight activities, such as for the licensing of doctors; audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
• Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
• Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
• Uses or disclosures for health related research;
• Uses and disclosures to prevent a serious threat to health or safety;
• Uses or disclosures for specialized government functions, such as for protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
• Disclosures of de-identified information;
• Disclosures relating to worker’s compensation programs;
• Disclosures of a “limited data set” for research, public health, or health care operations;
• Incidental disclosures that are an unavoidable by-product of permitted uses of disclosures;
• Disclosures to “Business Associates” who perform health care operations for us, and who commit to respect the privacy of your health information.

APPOINTMENT REMINDERS

                We may telephone or write to remind you of scheduled appointments or to change an appointment.  We may telephone or write to notify you of a procedure or a surgery we have scheduled for you at one of the doctor’s (above) request.  We may also telephone or write to notify you of other treatments or services available at our office that might help you.  This contact may be on an answering machine or other method, which could (potentially) be received or intercepted by others.  This call or message may be at a home or work number.  You can ask us to use other methods and we will comply.    

OTHER USES AND DISCLOSURES

                We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.”  The content of an “authorization form” is determined by federal law.  Sometimes, we may initiate the authorization process if the use or disclosure is our idea.  Sometimes, you may initiate the process if it is your idea for us to send your information to someone else.  Typically, in this situation you will give us a properly completed authorization form or you can use one of ours.

                If we initiate the process and ask you to sign an authorization form, you do not have to sign it.  If you do not sign the authorization, we cannot make the use or disclosure.  If you do sign the authorization, you may revoke it at any time unless we have already acted in reliance upon it.  Revocations must be in writing.  Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information.  You can:

• Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations.  We do not have to agree to do this, but if we agree, we must honor the restrictions that you want.  To ask for a restriction, send a written request to the office contact person at the address or fax shown at the beginning of this Notice.

• Ask us to communicate with you in a confidential way, such as phoning you at work rather than at home, or by mailing health information to a different address.   We will accommodate these requests if they are reasonable and if you pay us the extra cost, if any are incurred.  If you want to ask for confidential communications, send a written request to the office contact person at the address or fax shown at the beginning of this Notice.

• Ask to see or to get photocopies of your health information.  By law, there are a few limited situations in which we can refuse to permit access or copying.  For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us  (or 60 days if the information is stored off-site).  You may have to pay for photocopies in advance.  If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally available.  By law, we can have one 30-day extension of the time for us to give you access or photocopies if we send you a written notice of the extension.  If you want to review or get photocopies of your health information, send a written request to the office contact person at the address or fax shown at the beginning of the Notice.

• Ask us to amend your health information if you think that it is incorrect or incomplete.  If we agree, the information will be amended within 60 days of the requested date.  We will send the corrected information to persons who we know got the wrong information and others that you specify.  If we do not agree, you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we may write.  Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information.  By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension.  If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the above address or fax shown at the beginning of this Notice.

• Get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want).  By law, the list will not include:  disclosures for purposes of treatment, payment or health care operations; disclosures that were made with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures.  You are entitled to one such list per year without charge.  If you want more frequent lists, you will have to pay for them in advance.  We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of time if we notify you of the extension in writing.  If you want a list, send a written request to the office contact person at the address or fax shown at the beginning of this Notice.

• Get additional paper copies of this Notice of Privacy Practices upon request.  It does not matter whether you got one in paper form already.  If you want additional paper copies, send a written request to the office contact person at the address or fax shown at the beginning of this Notice.

OUR NOTICE OF PRIVACY PRACTICES

                By law, we must abide by the terms of this Notice of Privacy Practices.  We reserve the right to change this notice at any time as allowed by law.  If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future.  If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office.

COMPLAINTS

                If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the US Department of Health and Human Services, Office for Civil Rights.  We will not retaliate against you if you make a complaint.  If you want to complain to us, send a written complaint to the office contact person at the address or fax shown at the beginning of this Notice.  If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

                If you want more information about our privacy practices, call or visit the office contact person at the address or phone number at the beginning of this Notice.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of Michigan Otolaryngology Surgery Associates, and MOSA Audiology’s,

Notice of Privacy Practices and Financial Policy.

Patient Name _____________________________________________________

If above patient is a minor, other than the parent(s) listed in our Medical chart (MOSA’s) person(s) listed below are authorized to discuss treatments and business issues in person and over the phone on my behalf:

NAME OF PERSON:

_____________________________________________

Relationship to patient:

___________________________________________

NAME OF PERSON:

_____________________________________________

Relationship to patient:

__________________________________________

NAME OF PERSON:

_____________________________________________

Relationship to patient:

___________________________________________

NAME OF PERSON:

_____________________________________________

Relationship to patient:

___________________________________________

Health information that is NOT to be released or discussed with ANYONE other than the above patient, or the accompanying parent, please initial below.

Initial here:   ____________________

 Patient (or Parent of a Minor patient)

Signature

_____________________________________________

Date   ___________________________________

This form should be updated (initial & re-date) every year to remain Valid; unless revoked  in writing by above patient or responsible parent.

MOSA Representative/Witness:        

______________________________________

FINANCIAL POLICY

Thank you for choosing Michigan Otolaryngology Surgery Associates/MOSA Audiology Services (referred to hereafter as MOSA) as your healthcare provider.  We are committed to your treatment being successful.  The following is our FINANACIAL POLICY, which we require you to read and sign prior to any treatment.

IF YOU ARE NOT COVERED BY AN INSURANCE COMPANY AND/OR YOU DO NOT PRESENT YOUR INFORMATION/CARD TO US, payment in full is expected at the time of service, unless prior arrangements have been made with our Billing Department.  Methods of payment include: Cash, check, VISA, Master Card, and Care Credit.

Your insurance policy is a contract between you and your insurance company.  We are not a party to that contract.  Please be aware that some, and perhaps all of the services provided to you, may be non-covered services and not considered reasonable and necessary by your insurance company.  If your insurance carrier is contacted to obtain benefit information it is not a confirmation or guarantee of payment or benefits.  Your insurance company will determine what benefits are payable once a claim has been submitted.  Any co-payment collected from you at the time of service is an estimate of your financial responsibility.  You are ultimately responsible for the bill in its entirety.  Your insurance is being billed by our office as a courtesy to you.

There are certain insurance companies we (MOSA) participate with and accept their payment as payment-in-full, excluding any co-payments or deductibles indicated in your contract.  You are required to know the rules and regulations of your insurance carrier and obtain any required referrals or documentation in accordance with those rules.  A referral for treatment is not an assurance of authorization of payment.  Your insurance company may still deny the charges.  You are responsible for the bill in its entirety should your insurance company deny payment.

USUAL AND CUSTOMARY RATES—MOSA is committed to providing the best treatment for our patients.  Our charges are usual and customary for our area.  You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

WORKERS’ COMPENSATION and/or AUTO CLAIMS—The date-of-injury, contact name and phone number, billing address and claim number must all be presented at the time of the appointment.  If this information is NOT available, payment in full is expected from patient at the time of service.

MINOR PATIENTS—The adult(s) accompanying a minor and/or both parents (guardians of the minor) are responsible for full payment.  In the event the parents are divorced, the parent accompanying the minor is financially responsible, regardless of the divorce decree.  Settlement must be resolved between the parents.  For unaccompanied minors, non-emergency treatment may be denied.

Please understand that we cannot, as a third-party, become involved in prolonged insurance negotiation, this is your responsibility.

By signing the “ACKNOWLEDGEMENT OF RECEIPT” I agree to keep my account with MOSA current as to charges for which I am responsible for.  In the event I fail to pay charges, MOSA is entitled to take whatever action necessary to collect such charges.  I will be responsible for reasonable attorney fees and costs incurred as a result of such collection.

For more information, please visit http://www.hhs.gov/ocr/privacy/index.html