Insurance Disclaimer: "A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms conditions, limitations, and exclusions of the members contract at time of service" Insurance Liability for Payment: Your health insurance company will only pay for services that it determines to be "reasonable and necessary." Every effort will be made by this office to have all services and procedures preauthorized by your health insurance company, when applicable. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service. We suggest to all patients that they contact their insurance to confirm that these services are

Under this arrangement, you are responsible for paying your co-pay and any non-covered portions, and any deductible you have yet to cover. In addition, if your insurance does not pay for our services you agree to pay for the services provided in our clinic. Beneficiary Agreement: I understand that my health insurance company may deny payment for the services identified above, for the reasons stated. If my health insurance company denies payment, I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, deductible, or coinsurance that apples.

Signing below means that you received, understand this notice, and consent to your insurance being billed or consent to being responsible for the consultation fee. All your questions have been answered to your satisfaction. MCFRM does not collect any co- payments in the office.

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the doctor.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Attention New & Established Patients

We kindly request a minimum of 24-hours' notice for any cancellations of your scheduled appointment.

Upon your first no-show, a $50 fee will be charged to your account. Upon your second no-show an additional 75$ fee will be charged to your account. If you have no-showed two or more times, MCFRM reserves the right to discharge you from the practice. This policy applies to new and established patients and will be charged directly to the patient/guarantor, not to the patient's insurance. These charges must be paid before you are seen again.

 

Please check in with the front desk periodically or refer to our notice boards posted in the waiting room for any changes. If you are discharged, you will be required to be reevaluated before you can be seen again. It is your responsibility to keep track of your appointments. For convenience, MCFRM offers text message or email appointment reminder along with printed schedules. Please notify the front desk if you would like to participate.

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.

Michigan Center for Regenerative Medicine (“Regenerative Medicine”) and its employees are dedicated to maintaining the privacy of your personal health information (“PHI”), as required by applicable federal and state laws. These laws require us to provide you with this Notice of Privacy Practices, and to inform you of your rights and our obligations concerning Protected Health Information, or PHI, which is information that identifies you and that relates to your physical or mental health condition. We are required to follow the privacy practices described below while this Notice is in effect.

A.   Permitted Disclosures of PHI. We may disclose your PHI for the following reasons:

1.   Treatment. We may disclose your PHI to a physician or other health care provider providing treatment to you.  We may disclose health information about you to other health care providers who are involved in your treatment.  These other providers may include, but are not limited to, physicians, nurses, technicians or personnel who are involved with the administration of your care.

      Doctors and other providers who may treat you at places other than Regenerative Medicine need access to the most complete information possible in order to make decisions about your care.  These providers are able to access your electronic and paper records from Regenerative Medicine for this purpose.  Also, when these providers have referred you to Regenerative Medicine for treatment, they are able to access your records and your health information to follow your treatment progress. 

2.   Payment. We may disclose your medical and non-medical information so the treatment and services you receive at Regenerative Medicine can be billed to (and payment can be collected from) you, an insurance company or other third-party.  For example, we may send a bill to you or to a third-party payor for the rendering of services by us. The bill may contain information that identifies you, your diagnosis and procedures and supplies used. We may need to disclose this information to insurance companies to establish insurance eligibility benefits for you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims.  If you have paid in full for a health care item or service, and you tell us that you do not wish your health plan to receive information about that item or service, we will not share that information with your health plan, unless we are required by law to do so.

3.   Health Care Operations. We may disclose your PHI in connection with our health care operations. Health care operations include quality assessment activities, reviewing the competence or qualifications of health care professionals, evaluating provider performance, and other business operations. For example, we may use your PHI to evaluate the performance of the health care services you received. We may also provide your PHI to accountants, attorneys, consultants and others to make sure we comply with the laws that govern us.

4.   Incidental Uses and Disclosures.  We may use or disclose your health information when it is associated with another use or disclosure that is permitted or required by law.  For example, conversations between doctors, nurses or other Regenerative Health personnel regarding your medical condition may, at times, be overheard.  Please be assured that we have appropriate safeguards to avoid these situations as much as possible. 

5.   Appointment Reminders.  We may use and disclose health information to remind you of an appointment you scheduled for a treatment or medical service at Regenerative Medicine.

6.   Emergency Treatment. We may disclose your PHI if you require emergency treatment or are unable to communicate with us.

7.   Family and Friends. We may disclose your PHI to a family member, friend or any other person who you identify as being involved with your care or payment for care, unless you object.

8.   Required by Law. We may disclose your PHI for law enforcement purposes and as required by state or federal law.  For example, the law may require us to report instances of abuse, neglect or domestic violence; to report certain injuries such as gunshot wounds; or to disclose PHI to assist law enforcement in locating a suspect, fugitive, material witness or missing person. We will inform you or your representative if we disclose your PHI because we believe you are a victim of abuse, neglect or domestic violence, unless we determine that informing you or your representative would place you at risk.  In addition, we must provide PHI to comply with an order in a legal or administrative proceeding.  Finally, we may be required to provide PHI in response to a subpoena discovery request or other lawful process, but only if efforts have been made, by us or the requesting party, to contact you about the request or to obtain an order to protect the requested PHI.

9.   Serious Threat to Health or Safety. We may disclose your PHI if we believe it is necessary to avoid a serious threat to the health and safety of you or the public.

10. Health Information Exchange.  Regenerative Medicine records transmits health information, including prescription information, electronically.  Health information is shared for the purposes outlined in this Notice and is protected electronically through local, state and national health information exchanges. 

11. Public Health Risks. We may disclose your PHI to public health or other authorities charged with preventing or controlling disease, injury or disability, or charged with collecting public health data.  Disclosure of health information about you for public health activities include to:

·       Prevent or control disease, injury or disability

·       Report births and deaths and participate in disease registries

·       Report child abuse or neglect

·       Report reactions to medications or problems with products

·       Notify people of recalls for products they may be using

·       Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

·       Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.  We will make this disclosure only if you agree, or when required or authorized by law.  

12. Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law. These activities include audits; civil, administrative or criminal investigations or proceedings; inspections; licensure or disciplinary actions; or other activities necessary for oversight of the health care system, government programs and compliance with civil rights laws.

13. Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order.  We also may disclose medial information about you in response to a subpoena, discovery request or other lawful process by someone involved in the dispute, but only if you have agreed to such a release.  However, your permission will not be required if the disclosure request has been signed by a judge or ordered by a court of law.

14. Law Enforcement.  We may disclose health information if asked to do so by a law enforcement official in the following situations.

·       In response to a court order, subpoena, warrant summons or similar process

·       To identify or locate a suspect, fugitive, material witness or missing person

·       If the information is about a victim of a crime and if, under certain limited circumstances, we are unable to obtain the person’s agreement to the disclosure

·       About a death we believe may be the result of criminal conduct

·       About criminal conduct at Regenerative Medicine

·       In emergency circumstance to report a crime, the location of the crime or victims, or the identity (description or location) of the person who committed the crime.

15. Research. We may disclose your PHI for certain research purposes, but only if we have protections and protocols in place to ensure the privacy of your PHI.

16. National Security and Intelligence Activities.  We may disclose your health information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

17. Third Parties.  We may disclose your health information to certain third parties with whom we contract to perform services on behalf of Regenerative Medicine.  If so, we will have written assurances from the third party that your information will be protected.

18. Workers’ Compensation. We may disclose your PHI to comply with laws relating to workers’ compensation or other similar programs.

19. Specialized Government Activities. If you are active military or a veteran, we may disclose your PHI as required by military command authorities. We may also be required to disclose PHI to authorized federal officials for the conduct of intelligence or other national security activities.

20. Organ Donation. If you are an organ donor or have not indicated that you do not wish to be a donor, we may disclose your PHI to organ procurement organizations to facilitate organ, eye or tissue donation and transplantation.

21. Coroners, Medical Examiners, Funeral Directors. We may disclose your PHI to coroners or medical examiners for the purposes of identifying a deceased person or determining the cause of death, and to funeral directors as necessary to carry out their duties.

22. Disaster Relief. Unless you object, we may disclose your PHI to a governmental agency or private entity (such as FEMA or Red Cross) assisting with disaster relief efforts.

B.   Disclosures Requiring Written Authorization.

1.   Not Otherwise Permitted. In any other situation not described in Section A above, we may not disclose your PHI without your written authorization.

2.   Psychotherapy Notes. We must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment or health care operations activities.

3.   Marketing and Sale of PHI. We must receive your written authorization for any disclosure of PHI for marketing purposes or for any disclosure which is a sale of PHI.

C.   Your Rights.

1.   Right to Receive a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice upon request.

2.   Right to Access PHI. You have the right to inspect and copy your PHI for as long as we maintain your medical record. You must make a written request for access to the Compliance Officer at the address listed at the end of this Notice. We may charge you a reasonable fee for the processing of your request and the copying of your medical record pursuant to state law. In certain circumstances we may deny your request to access your PHI, and you may request that we reconsider our denial. Depending on the reason for the denial, another licensed health care professional chosen by us may review your request and the denial.

3.   Right to Request Restrictions. You have the right to request a restriction on the use or disclosure of your PHI for the purpose of treatment, payment or health care operations, except for in the case of an emergency. You also have the right to request a restriction on the information we disclose to a family member or friend who is involved with your care or the payment of your care. However, we are not legally required to agree to such a restriction.

4.   Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your PHI to a health plan if the PHI pertains to health care services for which you paid in full directly to us.  To request restrictions, you must make a written request to the Compliance Officer at the address listed at the end of this Notice.

5.   Right to Request Amendment. You have the right to request that we amend your PHI if you believe it is incorrect or incomplete, for as long as we maintain your medical record. We may deny your request to amend if (a) we did not create the PHI, (b) is not information that we maintain, (c) is not information that you are permitted to inspect or copy (such as psychotherapy notes), or (d) we determine that the PHI is accurate and complete.

6.   Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of PHI made by us (other than those made for treatment, payment or health care operations purposes) during the 6 years prior to the date of your request. You must make a written request for an accounting, specifying the time period for the accounting, to the Compliance Officer at the address listed at the end of this Notice.

7.   Right to Confidential Communications. You have the right to request that we communicate with you about your PHI by certain means or at certain locations. For example, you may specify that we call you only at your home phone number, and not at your work number. You must make a written request, specifying how and where we may contact you, to the Compliance Officer at the address listed at the end of this Notice.

8.   Right to Notice of Breach. You have the right to be notified if we or one of our business associates become aware of a breach of your unsecured PHI.

D.   Changes to this Notice. We reserve the right to change this Notice at any time in accordance with applicable law. Prior to a substantial change to this Notice related to the uses or disclosures of your PHI, your rights or our duties, we will revise and distribute this Notice.

E.   Acknowledgment of Receipt of Notice. We will ask you to sign an acknowledgment that you received this Notice.

F.   Questions and Complaints. If you would like more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made regarding the use, disclosure, or access to you PHI, you may complain to us by contacting the Compliance Officer at the address and phone number at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file such a complaint upon request.

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

Please direct any of your questions or complaints to:

To file a complaint with Regenerative Medicine, email

Michigan Center for Regenerative Medicine

Compliance Officer

109 S. Main St.

Rochester, MI 48307

 

All complaints must be submitted in writing.  You will not be penalized for filing a complaint. 

 

This notice is effective March 12, 2021.

 

I have received the Notice of Privacy Practices for Regenerative Medicine.