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Dearborn Obstetrical Gynecological Associates, P.C.

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Patient Privacy

NOTICE OF PRIVACY PRACTICES For Dearborn Obstetrical & Gynecological Associates, P.C. (referred to in this document as “the practice”)


This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposed that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. You “protected health information” means any of your written and oral health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

I. Uses and Disclosures of Protected Health Information

The practice may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the Practice has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA Privacy Regulations or State law. Disclosures of your protected health information for the purposes described in this Notice may be made in writing, orally, or by facsimile.


A. Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party for treatment purposes.


B. Payment. Your protected health information will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurer to get approval for the treatment that we recommend.


C. Operations. We may disclose your protected health information, as necessary, for our own health care operations in order to facilitate the function of the practice and to provide quality care to all patients.


D. Other Uses and Disclosures. As part of treatment, payment and healthcare operations, we may also use of disclose your protected health information for the following purposes:

• To remind you of an appointment.

• To inform you of potential treatment alternatives or options.

• To inform you of health-related benefits or services that may be of interest to you.


II. Uses and Disclosures beyond Treatment, Payment, and Health Care Operations Permitted Without Authorization or Opportunity to Object Federal privacy rules allow us to use and disclose your protected health information without your permission or authorization for a number of reasons including the following:

A. When Legally Required.

B. When There Are Risks to Public Health.

C. To Report Abuse, Neglect or Domestic Violence.

D. To Conduct Health Oversight Activities

E. In Connection with Judicial and Administrative Proceedings.

F. For Law Enforcement Purposes.

G. To Coroners, Funeral Directors and for Organ Donation.

H. For Research Purposes.

I. In the Event of a Serious Threat to Health or Safety.

J. For Specified Government Functions.

K. For Worker’s Compensation.

III. Uses and Disclosures Permitted Without Authorization but with Opportunity to Object

We may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the person’s involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.

IV. Uses and Disclosures Which you Authorize

Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

V. Your Rights

You have the following rights regarding your health information:

A. The right to inspect and copy your protected health information.

B. The right to request a restriction on uses and disclosures of your protected health information.

C. The right to request to receive confidential communications from us by alternative means or an alternative location

D. The right to have your physician amend your protected health information.


E. The right to receive an accounting.


F. The right to obtain a paper copy of this notice.

VI. Our Duties

The practice is required by law to maintain the privacy of your health information and to provide you with this written Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. If the practice changes its Notice, we will provide a copy of the revised Notice by sending a copy of the Revised Notice via regular mail, e-mail or through in person contact.

VII. Complaints You have the right to express complaints to the practice and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the practice by contacting the practice’s Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

VIII. Contact Person The practice’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards in the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. Complaints against the practice can be mailed to the Privacy Officer by sending it to:

Dearborn Obstetrical & Gynecological Associates, P.C. 25080 Michigan Avenue Dearborn, MI 48124 ATTN: Privacy Officer

The Privacy Officer can be contacted by telephone at 313-730-8880.

IX. Effective Date

This Notice is effective April 14, 2003.