Your provider is a member of the Envision Medical Group. Statements for services rendered will come in an Envision Medical Group envelope.
The statement will note the location where you received services. If you received lab or x-ray services that day, you will receive a separate statement. If your insurance plan does not cover our lab services, we will forward your specimen to a reference laboratory for processing. The bill for those services will come from that lab facility. Please check with our office if you have any questions. Please review your statements for accuracy and contact us if you have any concerns. We thank you for the opportunity to serve you.
If you have any billing questions, please call 1 (855) 712-6130.
Please contact your doctor’s office to ensure we participate with your insurance provider.
- Aetna Better Health
- Amerihealth via Olympia Medical Services
- Beaumont UMR
- Blue Cross Complete
- Cigna via HAP
- First Health/Coventry
- HAP – Health Alliance Plan
- HAP Midwest Health Plan
- Humana ChoiceCare
- Meridian Health Plan of Michigan
- Michigan Complete Health (formerly Fidelis)
- Molina via United Outstanding Physicians
- Oscar via Together Health
- Priority Health Plan
- RR Medicare
- Total Health Care
- Tricare East (Humana Military)
- UHC Commercial
- UHC Community
- UHC Medicare
Notice of Privacy Practices
All employees, staff, and those involved with your treatment, payment, or the operations of our offices will follow this notice. We are required by law to:
- Make sure that medical information that identifies you is kept private.
- Give you this notice of our legal duties and privacy practices with respect to your information, and follow the terms of the notice that is currently in effect. How we will use and disclose medical information about you:
- Treatment. We will use medical information about you to provide you with treatment or services. We will disclose covered information about you to others who also are involved in your treatment or taking care of you. For example, other healthcare providers, labs, physical therapy, Medicare or Medicaid, or your family or friends who are involved in your care decisions. We will also provide your referring physician or subsequent health care provider with copies of various reports to assist him or her in treating you.
- Payment. We will use and disclose covered information about you so that the treatment and services you receive can be billed to and payment may be collected from you, your insurance
company or a third party.
- Health care operations. The law permits us to use and disclose covered information about you for the operation of our practice. These uses and disclosures are necessary to run the practice and make sure all patients receive quality care.
- Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, or your location and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided us; e.g., on an answering machine.
- Business associates. There are some functions or activities that are provided for our organization through “contracts” with third-party “business associates.” Examples include consultants and attorneys. When these services are contracted we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do. To protect your health information we require the business associates to agree in writing to appropriately safeguard your information.
- Communication with individuals involved in your care. Health professionals, using their best judgment, may disclose to a family member, other relatives, close personal friend, or any other person you identify, health care information relevant to that person’s involvement in your care, or payment related to your care. We may also disclose private health information of deceased patients to a family member, friend, or representative (even absent probate) if that individual had been involved in the deceased patient’s care or payment before death unless disclosure would be inconsistent with the patient’s wishes expressed to us in writing.
- Research. Under certain circumstances, we may use and disclose medical information about you for research projects. We will ask for your specific authorization if the research information
includes items of your identity.
- Where required by law. We will disclose information about you where required by local, state, or federal law. For example, federal law may require your health information to be released to an appropriate health oversight agency, public health authority, or attorney.
- Coroners, medical examiners, funeral directors. We will release medical information about you if necessary, for example, to identify a deceased person or determine the cause of death.
- Public health. We will disclose medical information about you for public health activities. These activities generally include the following:
- To prevent or control disease, injury or disability.
- To report child or adult abuse, neglect or exploitation.
- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
- To 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 when required or authorized by law.
- To report births and deaths
- To report reactions to medications or problems with a product.
- Worker’s compensation. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs which may apply to your condition.
- Lawsuits and disputes. We will disclose health information about you in response to a court or administrative order, subpoena, discovery request, or other lawful purposes.
- Health oversight activities. We will disclose medical information about you to a health oversight agency for activities authorized by law. For example, audits, investigations, inspections, peer review, credentialing, and licensure.
- Military and veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel when necessary.
- Organ and tissue donations. If you are an organ donor, we may release your medical information to an organization that handles organ procurement or organ eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
- Other uses of medical information. Certain ways that your protected health information could be used or disclosed require authorization from you: use or disclosure for marketing and disclosures or uses that constitute a sale of protected health information. We cannot disclose your protected health information to your employer or to your school without your authorization unless required by law. Other uses and disclosures not described in this notice will be made only with your written authorization, which you may revoke going forward in writing.
Your Rights Regarding Medical Information About You
- Access to and copies. You have the right to access your records and /or to receive a copy of your records. Your request must be in writing. We are required to allow access or provide the copy within 30 days of your request. We may provide the copy to you or to your designee in an electronic format acceptable to you, or as a hard copy. We may charge you our cost for making and providing the copy. If your request is denied, you may request a review of this denial by a licensed health care provider.
- Right to amend. Your medical records are legal documents that provide crucial information regarding your care. You have the right to request an amendment to your medical records, but you must make this request in writing and understand that we are not required to grant this request.
- Right to an accounting of disclosures. This is a list of the disclosures we made of your medical information that was not related to treatment, payment, or operation of the office as we have listed. To request this accounting of disclosures, you must submit your request in writing. You are entitled to one accounting without change. You may be charged for subsequent lists. You
will be told the cost involved and may withdraw or modify your request. In the event of unauthorized disclosures we are obligated to notify you of this event and what information, if any, was disclosed without authorization.
- Right to request restrictions. You have the right to request restrictions on how your protected health information is used for treatment, payment, and health operations. For example, you may request that a certain friend or family member not have access to this information. We are not required to agree to this request, but if we agree to your request, we are obligated to fulfill the request, except in an emergency where this restriction might interfere with your care. We may terminate these restrictions if necessary to fulfill treatment and payment. We are also required to grant your request for restriction if the requested restriction applies only to information that would be submitted to a health plan for payment for a health care service or item or for health operations, if you have paid for the item or service in full “out‐of‐pocket”, and if the restriction is not otherwise forbidden by law. For example, we are required to submit information to federal health plans and managed care organizations even if we request a restriction. We must have your restriction documented prior to initiating the service. Some exceptions may apply, so ask for a form to request the restriction and to get additional information. We are not required to inform other covered entities of this request, but we are not allowed to use or disclose the information that has been restricted to business associates that may disclose the information to the health plan.
- Right to request confidential communications. You have the right to request confidential communications. For example, you may prefer that we call your cell phone number rather than your home phone. These requests must be in writing and may be revoked in writing and must give us an effective means of communication for us to comply. If the alternate means of communications incurs additional cost, that cost will be passed on to you.
- Right to a paper copy of this notice. You have the right to a paper or electronic copy of this notice. You may ask us to give you a copy of this notice at any time.
- Changes to this notice. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the notice that is in effect in the office and have a copy of the current notice available for you upon request.
- Complaints. You have the right to file a complaint without being penalized. If you believe your privacy rights have been violated, you may file a complaint in writing to the office manager.
You also have a right to file a complaint regarding privacy violations to the Office for Civil Rights. You will not be penalized for filing a complaint.
Privacy Officer Phone Number: 248‐741-6909
Office for Civil Rights
File HIPAA Complaint Online
We will be asking you to sign an acknowledgment of our office providing you with this Privacy Notice as required by HIPAA (Health Insurance Portability and Accountability Act of 1996) Privacy and Security rules. Your signature does not obligate you in any way. It simply verifies that we notified you of privacy standards and your rights.
Revised: January 25 ,2016