NOTICE OF PRIVACY PRACTICES

EFFECTIVE APRIL 13, 2003

As Required by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW CAREFULLY

OUR COMMITMENT TO YOUR PRIVACY

Our organization is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

To summarize, this notice provides you with the following important information:

How we may use and disclose your identifiable health information
Your privacy rights for your identifiable health information, and
Our obligations concerning the use and disclosure of your identifiable health information.

The terms of this notice apply to all records containing your identifiable health information that are created or retained by our office. Any revisions or amendments to this notice will be effective for all of your records our office has created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our office in a prominent location, and you may request a copy of our most current notice during any office visit.

If you have any questions regarding this notice please contact:

Julee Brown, DME Manager

Watkins Surgical Supply

1391 E Sherman Blvd, Muskegon, MI 49444

PH: (231) 739-7158 ext 360

WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS:
Treatment: Our organization may use your identifiable health information to provide services for you. For example, we may ask for the results of laboratory tests (such as blood or urine) to provide services that are relevant to your diagnosis. Some of the people who work for our organization may use or disclose your identifiable health information in order to provide services or assist others in providing services. Additionally, we may disclose your identifiable health information to others who may assist in your care such as your physician, therapists, or home healthcare. We may also provide information to your spouse, children or parents with your permission.
Payment: Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits) and we may provide your insurer with details regarding your treatment to determine if your insurer will cover or pay for your treatment or services. We also may use and disclose your pay for your treatment or services. We also may use and disclose identifiable health information to obtain payment from third parties that may be responsible for such costs, such as family members with Power of Attorney. Also, we may use your identifiable health information to bill you directly for services and items.
Health Care Operations: Our organization may use and disclose your identifiable health information to operate our business. For example, our organization may use your health information to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our organization.
Appointment Reminders: Our organization may use and disclose your identifiable health information to contact you for delivery or services.
Release of Information to Family/Friends: Our organization may release your identifiable health information to a friend or family member that is helping you pay for your health care or who assist in taking care of you.
Disclosures Required by Law: Our organization will use and disclose your identifiable health information when we are required to do so by Federal, State or Local law.
USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES
Public Health Risks: Our organization may disclose your identifiable health information to public health authorities that are authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths
Reporting child abuse and neglect
Preventing or controlling disease, injury or disability
Notifying a person regarding potential exposure to a communicable disease or condition
Reporting reactions to drugs or problems with products or devises
Notifying individuals if a product or devise they may be using has been recalled
Notifying appropriate government agencies and authorities regarding potential abuse or neglect of an adult parent (including domestic violence), however we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information, notify your employer under limited circumstances related primarily to workplace injury, illness, or medical surveillance.

Health Oversight Activities: Our organization may disclose your identifiable information to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, 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 right laws and the health care system in general.
Lawsuits and Similar Proceedings: Our organization may use and disclose your identifiable health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
Law Enforcement: We may release identifiable health information if asked to do so by a law enforcement official:

Regarding a crime victim in certain situations, if we are unable to obtain the persons agreement
Concerning a death we believe might have resulted from criminal conduct
Regarding criminal conduct at our office
In response to a warrant, summons, court order, subpoena or similar legal process
To identify/locate a suspect, material witness, fugitive or missing person
In an emergency, to report a crime (including the location or victim of the crime or the description, identity or location of the perpetrator)

Serious Threats to Health or Safety: Our organization may use and disclose your identifiable health information when necessary to reduce/prevent a serious threat to your health and safety, the health/safety of another individual, or the public. Under these circumstances we will only make disclosures to a person or organization able to prevent the threat.
Military: Our organization may disclose your identifiable health information if you are a member of the U.S. or foreign military forces (including veterans), and it is required by the appropriate military command authorities.
National Security: Our organization may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
Inmates: Our organization may disclose your identifiable health information to correctional institutions or law enforcement officials. If you are an inmate or under the custody of a law enforcement official, disclosure for these purposes would be necessary for: The institution to provide health care services to you, the safety and security of the institution, or to protect your health and safety or the health and safety of other individuals
Workers Compensation: Our organization may release your identifiable health information for worker’s compensation or similar programs.

WATKINS PHARMACY & SURGICAL SUPPLY

PATIENTS RIGHTS AND RESPONSIBILITIES

RIGHTS

You, as a patient of Watkins Pharmacy & Surgical Supply, have the right to…

Be fully informed in advance about service/care to be provided, including the disciplines that furnish care and the frequency of visits, as well as, any modifications to the service/care plan
Participate in the development and periodic revision of the plan of service/care
Informed consent and refusal of service/care/treatment after the consequences of refusing service/care/treatment are fully presented
Be informed, both orally and in writing, in advance of service/care being provided, of the charges, including payment for service/care expected from third parties, and any charges for which the client/patient will be responsible
Have one’s property and person treated with respect, consideration, and recognition of client/patient dignity and individuality
Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries unknown source, and misappropriation of client/patient property
Be able to identify visiting staff members through proper identification
Voice grievances/complaints regarding treatment or care, lack of respect of property or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal. All findings will be addressed within 5 days of reporting the incident
Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated
Choose a health care provider
Confidentiality and privacy of all information contained in the client/patient record
Be advised on agency’s policies and procedures regarding the disclosure of clinical records
Receive appropriate service/care without discrimination in accordance with physician orders
Be informed of any financial benefits when referred to an organization
Be fully informed of one’s responsibilities
Be informed of provider service/care limitations

RESPONSIBILITIES

You, as a patient of Watkins Pharmacy & Surgical Supply are responsible for…

Notifying Watkins when you will not be available for scheduled services/visits
Notify Watkins of a change of address
Notifying Watkins of any change in physician or insurance coverage
Notify Watkins of needed equipment repair
Notifying Watkins when equipment is no longer needed so that pick-up may be arranged
Notifying Watkins of any undue incident involving staff or equipment
Proper care/maintenance of rental equipment and returning equipment in good working condition
Payment for any service/equipment not covered by your insurance

YOUR RIGHT REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION

You have the following rights regarding the identifiable health information that we maintain about you:

Confidential Communications: You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request confidential communication, you must send a written request to Julee Brown, DME Manager, Watkins Surgical Supply, 1391 E. Sherman Blvd, Muskegon, MI 49444 (231) 739-7158 ext 360 specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests.
Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your identifiable health information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to provide services to you. In order to request a restriction in our use of disclosure of your identifiable health information you must make your request in writing to Julee Brown, DME Manager, Watkins Surgical Supply, 1391 E. Sherman Blvd, Muskegon, MI 49444 (231) 739-7158 ext 360. Your request must describe in a clear and concise fashion: the information you wish restricted, whether you are requesting to limit our organization use, disclosure or both, and to whom you want the limits to apply
Inspection and Copies: You have the right to inspect and obtain a copy of the indefinable health information that may be used to make decisions about you, including patient medical records, excluding psychotherapy notes, and billing records. You must submit your request in writing to Julee Brown, DME Manager, Watkins Surgical Supply, 1391 E Sherman Blvd, Muskegon, MI 49444 (231) 739-7158 ext 360 in order to inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our organization may deny your request to inspect and/or copy in certain limited circumstances, however, you may request a review of our denial. Reviews will be conducted by another member of our staff chosen by us.
Amendment: You may ask us to amend your health information if you believe it is incorrect or incomplete and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be submitted in writing to Julee Brown, DME Manager, Watkins Surgical Supply, 1391 E. Sherman Blvd, Muskegon, MI 49444, (231) 739-7158 ext 360. You must provide us with the reason supporting your request in writing. Also, we may deny your request if you ask us to amend information that is:

Accurate and complete
Not part of the identifiable health information kept by or for our organization
Not part of the identifiable health information which you would be permitted to inspect and copy

Accounting of Disclosures: All of our patients have the right to request an “accounting of disclosures”. An “accounting of disclosures” is a list of certain disclosures our organization has made of your identifiable health information. In order to obtain an “accounting of disclosures” you must submit your request in writing to Julee Brown, DME Manager, Watkins Surgical Supply, 1391 E Sherman Blvd, Muskegon, MI 49444 (231) 739-7158 ext 360. All requests for an “accounting of disclosures” must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our organization may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests and you may withdraw your request before you incur any costs.
Right to A Paper Copy of this Notice: You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice contact any staff member at Watkins Surgical Supply, 1391 E. Sherman Blvd, Muskegon, MI 49444 (231) 739-7158.
Right to File a Complaint: If you believe that your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services or with our accreditation organization ACHC (Accreditation Commission for HealthCare inc). You will not be penalized for filing a complaint.
Right to Provide an Authorization for Other Uses and Disclosures: Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note, we are required to retain records for your care and services.

CREDIT/COLLECTION DEPARTMENT

1391 E. SHERMAN BLVD, MUSKEGON, MI 49444

(231) 739-7158 OR (800_ 777-2717

FINANCIAL POLICY

Watkins Surgical Supply has established the following revised payment policy effective March 1, 2003

Fees must be paid by one of the following terms:

Watkins Surgical Supply will submit claims to insurance plans according to the terms of the individual agreements with the insurance company when they exist. The patients co-insurance is due at the time of service and is payable by cash, check, MasterCard, Visa, Discover or American Express. A service charge of 1.5% will be added to any account with a balance over 30 days past due to cover the costs incurred to send additional statements.

In the instance where the insurance plan of the patient is not under contract with Watkins Surgical Supply, our policy is to submit the claim to the insurance company as a courtesy to the patient. Prompt Pay Law in Michigan states the insurance company is to pay within 45 days of receipt of the claim. It is the patient’s responsibility to follow up with their insurance company. The Privacy Act prohibits Watkins Surgical Supply from obtaining information on the processing of an unassigned claim.

Routine waiver of Medicare co-insurance and deductible is considered fraud under Medicare guidelines and therefore against the law. It is possible on a case-by-case basis for Watkins Surgical Supply to declare an account as a “charity/hardship” account and assist patients with financial difficulties.

Balances that are “ patient responsibility” to include non-covered services, 60-day aged accounts, deductibles, denied services and self-pay are payable by one of two methods: (Self-Pay is defined as patient without insurance, motor vehicle accidents and “other liability” accidents)
Paid in Full
3 equal monthly payments until paid in full

Secondary insurance claims will be submitted as a courtesy to the patient. However, the patient will remain responsible for the balance except in the instances where Watkins Surgical Supply is in contractual arrangement with the secondary insurance. The above “patient responsibility” rule will apply.

Watkins Surgical Supply makes every attempt to collect delinquent accounts in-house. Failure to abide by our payment policies will put the patient at risk of being placed with a collection agency. Once an account is placed with an agency, the patient must deal directly with that collection agency. Therefore, prompt payment is encouraged.

FAMILY EMERGENCY PLAN

Make sure your family has a plan in case of an emergency or a natural disaster. Before an emergency or disaster happens, sit down together and decide how you will get in contact with each other, where you will go and what you will do in an emergency. Keep a copy of this plan in your emergency supply kit or another safe place where you can access it in the event of a disaster. Below are a few examples of items you may want to consider when making an emergency plan:

Names and dates of birth for family members living in your home
Emergency contact (someone living outside of your home)
Major medical conditions for you and your family members
Neighborhood meeting place
Evacuation location
Names, phone numbers, and addresses of employees
Doctors and their phone numbers
Pharmacies and their phone numbers
Medical/Homeowners/Rental/Life Insurance policy numbers and contact numbers
A safe-box to store all the information in, that is easily accessible in an emergency

You may also want to include:

Any medications that you or your family are taking
Dosages of medications
Allergies to medications, foods, or environmental substances
Out of town contact
Any wills, living wills, power of attorney documents
Food, water, and a supply of medication and medical supplies

Please always remember to dial 911 for emergencies

Notice of Patient Privacy Practices

NOTICE OF PRIVACY PRACTICES

PLEASE REVIEW CAREFULLY

PATIENTS RIGHTS AND RESPONSIBILITIES

RIGHTS