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The Health Insurance Portability and Accountability Act of 1996 (HIPPA) is a Federal program that requests that all medical records and otherindividually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properlyconfidential. This act gives you, the patient, the right to understand and control how your protected health information (PHI) is used. HIPPA providespenalties for covered entities that misuse personal health information.

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

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

1. Treatment means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. An example of this is Dr. Roufaida Al-Misky referring you to a specialist physician.
2. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing activities, and utilization review. An example of this would include sending your insurance company a bill for your visit.
3. Healthcare operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service.
4. The practice may also be required or permitted to disclose your PHI for law enforcement as required by federal, state or local law and other legitimate reasons. In all situations, we shall do our best to assure its continued confidentially to the extent possible.

We may contact you by phone, email, text or in writing, to provide appointment reminders or your medication at a pharmacy is ready or information about treatment alternatives or other health related benefits and services that may be of interest to you. 

Other ways your health information may be used or shared. We are allowed or required to share in ways that contribute to the public good, for example research and public health. Many conditions have to be met in the law before we can share this information.

https://www.hhs.gov/hipaa/index.html

1.Public health and safety issues. Our office may disclose your PHI to public health authorities to maintain vital records, report suspected abuse, neglect or domestic violence, report adverse reactions to medications or problems with products or devices, prevent disease, or prevent or reduce a serious threat to anyone’s health or safety or to the public.

2.Comply with the law. We will share information about you if state or federal laws require it. Our practice may use and disclose your PHI to a health oversight agency for activities authorized by law. This could include inspections, investigations, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the healthcare system in general. An example is the Department of Health and Human Services to determine if we are in compliance with federal privacy law.

3.Lawsuits and similar proceedings. Our practice may share your PHI in response to a court or administrative order or in response to a subpoena.

4.Our practice may release PHI to a medical examiner, or coroner or funeral director for a deceased Individual.

5. If you are an organ donor, our practice may release your PHI to organ procurement organizations for organ and tissue donation requests.

6. Our practice may use and disclose PHI for health research

7. We may disclose or share health information about you for workers compensation, law enforcement purposes or to law enforcement officials, or to special government requests for special government functions such as the military, national security and presidential protective services.

Other uses and disclosures of PHI not described in this notice will only be made pursuant to us receiving a written authorization from you. 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 prior authorization. Also, a written authorization is required for most uses or disclosures of psychotherapy notes. 

1.The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures to family members, or any other person identified by you, who may be involved in your care or for notification purposes. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it except when required by law, in emergencies or when information is necessary to treat you unless you agree in writing to remove it.

2. The right to reasonable requests to receive confidential communications of PHI by alternative means or at alternative locations.

3. The right to inspect and copy your PHI.

4. The right to amend your PHI. We may ask you to make the request in writing, and state the reason. We may so no but will tell you why in writing within 60 days.

5. The right to receive an accounting of disclosures of your PHI.

6. The right to obtain a paper copy of this notice from us upon request at any time. You can view a copy of this notice on our website familymedicineandwellness.com and in the lobby.

7. The right to choose someone to act for you. If a person has the authority to act for you, such as your medical power of attorney or legal guardian, that person can exercise your rights, and make decisions about your health information. You or your personal representative may need to provide authorizing paperwork before we can evaluate if the person has this authority and can act for you before we take any action.

8. The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

9. The right to limit what information we use or share. If you have paid for services “out of pocket”, in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.

10. You have the right and choice to tell us to share your information in a disaster situation.

We will comply with and abide by all applicable state and federal laws. For the state of Michigan there are more limits on the disclosure of HIV and AIDS, substance abuse information and mental health information.

We may participate in a Health Information Exchange that allows electronic transfer of PHI between healthcare providers to coordinate treatment.

We are required by law to maintain the privacy and security of your PHI. We must follow the privacy practices described in this notice and to provide you the notice of our legal duties and our privacy practices with respect to PHI.

This notice is effective as of August 1, 2021 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPPA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post a copy and you may request a written copy of the revised Notice of Privacy Practice from our office.

You have recourse if you feel that your protections have been violated by your office. You have the right to file a formal, written complaint with the practice and with the Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint. Visit https://www.hhs.gov/hipaa/filing-a-complaint/index.html, or write to 200 Independence Ave, SW Washington, DC 20201, or call 1-800-368-1019.

Please contact Dr. Al-Misky at 248-759-0993, or in person or in writing or info@dralmisky.com with questions or for more information regarding this notice or our health information privacy policies.

FAMILY MEDICINE AND WELLNESS, PLLC Roufaida N. Al-Misky, MD, FAAFP

1579 W BIG BEAVER RD, STE B05

TROY, MI 48084

Phone: 248.759.0993

Fax: 833.955.3554

INFO@DRALMISKY.COM

I give consent for Roufaida Al-Misky, MD, FAAFP of Family Medicine and Wellness, PLLC to perform and provide medicalcare, tests, or procedures as agreed upon in the best interest of my health.

In an effort to improve the quality and safety of our patient care, we may require your current prescription medications.I agree that Family Medicine and Wellness, PLLC may request my current prescription history from third party pharmacybenefit payors for treatment purposes.

I authorize Dr. Roufaida Al-Misky to bill my insurance carrier, and when needed to release any medical or personalinformation that is required to process the claim on my behalf. I acknowledge and agree that I am fully responsible forall costs incurred for my treatment in the office of Family Medicine and Wellness, PLLC. I understand payment and / orcopay is preferred on the date of service.