HIPAA Notice of Privacy Practices
This Notice describes the privacy practices of Cancer & Hematology Centers of Western Michigan, PC/START Midwest (CHCWM/START Midwest). All CHCWM/START Midwest
facilities, clinics, departments, offices, operations, and personnel will abide by this Notice.
Understanding Your Health Record/Information:
A record is made each time you visit a hospital, physician, or other healthcare providers. This record typically contains your symptoms, examination and test results, diagnoses,
treatment, and a plan for future care or treatment. We use your Protected Health Information (PHI), also referred to as your health or medical record or information, as a
basis for treatment, payment, and healthcare operations purposes. For other situations, we ask for your written authorization before using or disclosing information. To stop future
usage and disclosures, you may revoke your written authorization at any time.
We may change our policies at any time. Before making a significant change in our policies, we will change our notice and post the new notice in the waiting area. You may
request a copy of our Notice of Privacy Practices at any time.
It is our legal duty to maintain the privacy of your medical information that identifies you; give you this Notice of our legal obligations and privacy practices concerning medical
information about you, and follow the terms of the current Notice.
Uses and Disclosures:
● Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This disclosure includes the coordination or
management of your health care with a third party (i.e., to a physician you have been referred to so the physician has the necessary information to diagnose and treat you).
● Payment: We use and disclose PHI to obtain payment and reimbursement for our health care services. Please see our Financial Policy.
● Healthcare Operations: We may use and disclose your PHI to support the business activities of the practice.
● As Required by Law: Medical information will be disclosed about you when required to do so by federal, state, or local law or regulation.
● Abuse or Neglect: PHI may be disclosed to report child abuse or neglect. We may also notify the appropriate government authority if we believe a patient has been the victim
of abuse, neglect, or domestic violence, if you agree or if we are required or authorized by law.
● Treatment Alternatives: We may use and disclose PHI to inform you about or recommend possible treatment options or alternatives.
● Individuals Involved in Your Care or Payment for Your Care: We may disclose PHI to a friend or family member who is involved in your medical care. We may also give
information to someone who helps pay for your care. We may also tell your family or friends about your general condition. Also, we may disclose PHI to an entity, such as
the Red Cross, assisting in a disaster relief effort so your family can be notified about your condition and location.
● Appointment Reminders: We may use and disclose your medical information to provide you with appointment reminders or rescheduled appointment notices, etc. For example,
these types of reminders and notices may be sent via mail or voice message.
● Cancer Registry: We may disclose your PHI, i.e., diagnosis, to report to the state and national level cancer registries as required by state law.
● Communicable Diseases and Public Health Issues: We may disclose PHI for public health activities including: to prevent or control disease, injury, or disability; report
births and deaths; participate in disease registries; report reactions to medications or problems with products; notify people of recalls of products they may be using, and
notify a person who may have been exposed to a disease, is at risk for contracting, or spreading a disease.
● Inmates: We may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate of such institution or under the custody of such law
enforcement official. This disclosure would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of
others, or for the safety and security of the correctional institution.
● Military Activity: We may disclose your information as required by military command authorities if you are a member of the armed forces. We may also disclose medical
information about foreign military personnel to the appropriate foreign military authority. If a family member is in the military, we may disclose medical information
about you to the military or an approved social services agency such as the Red Cross to advise your family member of your condition.
● Coroners, Medical Examiners, and Funeral Directors: PHI may be disclosed to a coroner or medical examiner, this may be necessary to identify a deceased person or to
determine the cause of death. PHI may need to be disclosed to funeral directors as necessary for them to carry out their duties.
● Food & Drug Administration: PHI may be disclosed to the FDA in the event of a mandatory or voluntary drug recall, or to report adverse drug reactions to the drug
● Research: Medical information may be used and disclosed for research under certain circumstances. This may include comparing the health and recovery of all patients who
received one medication to those who received another, for the same condition. The use of PHI for research projects is subject to an approval process, and will not be used
or disclosed until the project has been approved through this process. Researchers are required to apply strict measures to protect the privacy of the information, by revealing
only the minimum information necessary to conduct the research and removing the individual’s key identifiers.
● Legal Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order, subpoena, or other lawful processes.
Your consent will not be required if a court of law has ordered the information disclosure.
● Organ Donation: If you are an organ donor, we may disclose medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation or
to an organ donation bank, as necessary.
● National Security: We may disclose personal medical information to authorized federal officials for intelligence, counterintelligence, and other national security activities
authorized by law.
● Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law. Examples include audits, investigations, inspections, and licensure.
● Law Enforcement: We may release PHI if asked to do so by law enforcement officials in response to a court order, subpoena, warrant, or summons issued by a judicial officer or
authority; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain circumstances, we are unable to obtain the
person’s agreement; about a death we believe may be the result of criminal conduct; as evidence of criminal conduct at our location; and in emergency circumstances to report
a crime, location of the crime or victims, or the identity, description, or location of the person who committed the crime.
● Workers’ Compensation: We may disclose your PHI for workers’ compensation or similar programs.
Your Rights Regarding Your Protected Health Information:
● Right to Inspect and Copy: You have the right to inspect and obtain a copy of PHI that may be used to make decisions about your care. This includes medical and billing
records but does not include psychotherapy notes. If you request copies, we may charge a fee for the costs of copying, mailing, or other supplies or charges incurred or
associated with your request. Your request must be made in writing. The request may be submitted at any CHCWM/ START Midwest office and addressed to the attention of
your office manager. Also available online at CHCWM.com.
● Right to Amend: If you believe the information in your record is incorrect or if relevant information is missing, you have the right to request a correction to existing
information or add the missing information. Your request to amend must be submitted in writing and must include the reason supporting your request. We may deny your
request if it is not made in writing or does not include a supporting reason. Other reasons your request may be rejected include: we did not create the record; the record
is not part of the medical information kept by or for a CHCWM/START Midwest entity; the record is not part of the information you would be permitted to inspect and copy
(i.e., psychotherapy notes); or if the record is complete and accurate. Your request may be submitted at any CHCWM/ START Midwest office and addressed to your office
● Right to an Accounting of Disclosures: You have the right to request a list or accounting of disclosures of your PHI. This lists the disclosures we made of PHI about you that
were not made for treatment, payment, and healthcare operations, or that were made without your authorization. Your request may not be more than six years prior to the
date of the request. Your first requested report within a 12-month period will be free, for additional lists, we may charge you for the costs of providing the list. We will notify
you of any fees, and you can modify or withdraw your request before any costs are incurred. Your request must be submitted in writing to the attention of your office
● Right to Request Restrictions: You may request restricted access to your PHI to prevent certain family members or other persons from gaining access to your information. It
would be best if you were very specific to whom and to what information will be restricted. The physician is not required to grant your request. If the physician feels it
would not be in your best interest, they may deny your request. You may also request, in writing, a restriction or limitation on the PHI we use or disclose for treatment,
payment, or healthcare operations purposes. We are not legally required to agree to your request to restrict the use or disclosure of your information. If we do agree to a
restriction, it will not apply to certain disclosures including when required by law, emergency circumstances, third-party payment contracts, and when transferring your
PHI to another health care facility.
● Right to Request Confidential Communications: You have the right to request us to communicate with you about medical matters in a certain way or at a specific location.
For example, you can ask us to only contact you at work or by mail. This request must be made in writing and must specify how and where you wish to be contacted. We will
not ask for the reason for your request. We will attempt to accommodate all reasonable requests.
● Right to a Paper Copy of this Notice: You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still
entitled to a paper copy of this Notice. You may request a copy of this Notice by contacting our office or online at CHCWM.com. (New Patient Information
Tab/Information Overview/Patient Forms)
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 may receive in the future. We will post a copy of the current Notice in the facilities covered by this Notice. The Notice will contain the effective date on the first
page. A new paper copy of this Notice will be made available to you at your request.
Complaints or Questions:
If you believe your privacy rights have been violated or have any questions regarding this Notice, you may contact our HIPAA Officer at (616) 954-9800 or mail to Cancer &
Hematology Centers of Western Michigan, PC/START Midwest, Attn: HIPAA Officer, 5800 Foremost Dr SE, Suite 300, Grand Rapids, MI 49546. We will not retaliate against you for
filing a complaint.
Other Uses of Protected Health Information:
You may designate other uses and disclosures of your PHI not covered by this Notice or applicable laws through written authorization. You may authorize or revoke the
authorization in writing at any time. After authorization is revoked, we will honor the revoked authorization, but cannot take back any disclosures made based on the
authorization prior to it being revoked.
CHCWM/START Midwest Mission Statement:
Cancer & Hematology Centers of Western Michigan/START Midwest is dedicated to help,
healing, and hope for cancer patients and their families.