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.

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 information about privacy practices followed by our employees, staff, and other office personnel.  It also describes your rights to access and control your protected health information in some cases. This notice applies to the information and records we have about your health, health status, and the healthcare and services you receive at this facility.

Uses and Disclosures of Medical Information

We will use or disclose your medical information for treatment, payment and health care operations.  For example:

Treatment: We may use or disclose your medical information to a physician or other health care provider in order to provide the best treatment to you.

Payment: We may use and disclose your medical information in order to receive payment for our services. We may bill and receive payment from you, an insurance company or a third party. We may need to disclose medical information in order to obtain authorization from your insurance for treatment that our doctors recommend or to determine if your insurance will cover the treatment.

Health Care Operations

We may use and disclose your medical information in our health care operations to ensure our patients are receiving the best possible care.  For Example:

  • Quality assessment and improvement activities such as case management and care coordination
  • Satisfaction surveys
  • Arranging for medical reviews, audits or legal services
  • Specified insurance functions such as underwriting, risk rating, and reinsuring risk
  • Business planning, development, management and administration
  • General administrative activities
  • Staff Education
  • We may remove personal identifying information in order to use the medical information for studies without learning the identity of the patient

Health Related Benefits and Services

We may use your medical information to tell you about health related products or services that may be of interest to you. Please notify us if you do not wish to be contacted about treatment alternatives or health related products and services. If you advise us in writing that you do not wish to receive this type of communication, we will not use or disclose your information for this purpose.

On your Authorization

Upon your authorization, we will use your medical information or disclose your medical information for any purpose. If you give us written authorization you may revoke it at any time.  If written authorization is not given to us, your medical information will not be disclosed except in the instances listed above.

Appointment Reminders

We may use and disclose medical information to contact you to remind you of an upcoming appointment. When required, a message will be left on a recording or with another person. If you do not wish for a message to be left, please inform us and we will not leave any messages on your voicemail or answering machine.

Family or Friends

Unless we have written notice, we will not disclose information to someone claiming to be a family member or a friend. We will only disclose medical information to specific people on your authorization. In the event of an emergency or your incapacity, we will use our professional judgment of whether the disclosure would be in your best interest.  We will assume that if a person escorted you to your appointment and is in the exam room with you, we have informal authorization to disclose information in front of that person.

By Law or Special Authorization

We may disclose or use your medical information as authorized by law for the following purposes as needed for public health or safety.

  • as required by law (statute, regulation or court orders)
  • public health activities such as preventing or controlling disease or reporting child abuse or neglect, FDA oversight, and employers regarding illness or injury
  • to report adult abuse, neglect or domestic violence
  • to health oversight agencies for audits, and investigations necessary for oversight of the health care system and government benefit programs
  • In response to court and administrative orders and other lawful purposes
  • to law enforcement as required by law (court orders, warrants, subpoenas, and administrative requests), to identify or locate a suspect, fugitive, material witness, or missing person, if protected health information can be used as evidence of a crime that occurred on the premises
  • to coroners, medical examiners and funeral directors for identification purposes
  • For organ, eye or tissue donation
  • in connection with certain research
  • to avert a serious threat to health or safety to a person or the public
  • essential government functions-military missions, lawful intelligence and national security activities, protecting the health and safety of inmates or employees in a correctional institution, determining eligibility for enrollment in certain government benefit programs
  • as authorized by state worker’s compensation laws

Specific Authorization

We must obtain written authorization from the patient for any use or disclosure of protected health information that is not for treatment, payment or health care operations. We may not condition treatment based on an individual granting an authorization. We must obtain your authorization in specific terms for the following situations.  The authorization must be in plain language and must contain specific information regarding the information being disclosed or used, the person disclosing and receiving the information, expiration, and the right to revoke in writing.

  • Psychotherapy notes require an individual’s authorization and the therapist’s authorization except when being used by the originator for treatment
  • Marketing requires authorization when the communication is about a product or service that requires the patient to purchase or use the product or service. Exceptions to the rule are when the product or service is for the treatment and care specific to that patient and when sample products are given during an office visit.

Your Rights Regarding Your Medical Information

You have the right to look at or get copies of your medical records with limited exceptions. You must make a request in writing to the Privacy Officer.  A fee may be charged at our discretion to cover the costs of printing, copying, mailing and accessing your records. If access to your records is denied, you may ask that the denial is reviewed. The person conducting the review will not be the same person who denied the request.  We will comply with the outcome of the review.

  • You have to right to request an amendment to your medical records if you feel there is inaccurate or incomplete medical information. The request must be in writing and explain why it should be amended. A form may be obtained by contacting the Privacy Officer. We may deny the request if we did not create the information you want amended.  If the request is denied, a written explanation will be provided to you. If denied, you are allowed to submit a statement of disagreement to be included in the medical record. If the request is accepted, we will make reasonable efforts to contact people identified by you who may need the information.
  • You have the right to request an accounting of disclosures of your protected health information. The maximum disclosure accounting period is six years prior to the request. Accounting of disclosures is not required for treatment, payment, healthcare operations, to the patient or patient’s representative, notification of or to persons involved in the patient’s healthcare or payment of healthcare, pursuant to an authorization, correctional institutions or law enforcement officials for patients in lawful custody, or incident to otherwise permitted or required uses or disclosures.
  • You have the right to request restrictions on the disclosure of certain medical information for treatment, payment, healthcare operations, disclosure to persons involved in your care, disclosure to notify family members regarding your condition, location or death. We are under no obligation to agree to the request. If we do agree to the request, we must comply with the restriction, except for the purpose of treating the patient in a medical emergency.
  • You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. For example, you may request that we contact you only at work, or on your cell phone. Such requests must be made in writing to our Privacy Officer.
  • You have the right to pay for services “out of pocket”, in full, and request in writing that we not disclose PHI related solely to those services to a health plan We will accommodate your request, except were we are required by law to make a disclosure.

Changes to This Notice

We reserve the right to change this Notice and to make the revision or changes effective for all medical information we already have about you as well as any information we receive in the future. If this notice is changed, we will post the new Notice in the waiting room. You may request a copy at any time.

Questions and Complaints

If you have any questions regarding our Privacy Policy, please contact our Privacy Officer using the information at the end of this notice.

If you are concerned that we have violated your privacy rights, disagree with any decisions we made about access to your medical information, wish to appeal a decision made regarding an amendment or restriction or disclosure to your medical records, or to have us communicate with you my alternative means, you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S Department of Health and Human Services.  We will provide you with the address to file you complaint with the U.S. Department of Health and Human Services upon your request.

We support your right to privacy of your medical information and will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services.


Contact Information

Great Lakes Gastroenterology

Great Lakes Endoscopy Center

3903 Hollywood Rd

St. Joseph, MI 49085

Attn: Privacy Officer

(269) 408-1100


December 1, 2016