Fusion Medical Supplies, LLC
NOTICE OF PRIVACY PRACTICES
Effective January 01, 2004

As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO YOUR IDENTIFIABLE HEALTH INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Fusion Medical Supply is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice practices that we have in effect at the time.

This notice provides you with the following important information:

• How we may use and disclose your identifiable health information
• Your privacy rights in your identifiable health information
• Our obligations concerning the use and disclosure of your identifiable health information

The terms of this notice apply to all records containing your identifiable health information that are created or retained by Fusion Medical Supply. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our company has created or maintained in the past, and for any of your records we may create or maintain in the future. Fusion Medical Supply will post a copy of our current notice in our corporate offices in a prominent location, and you may request a copy of the most current notice from our office or you can access it on our website at www.fusionmedical.com.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT FUSION MEDICAL SUPPLIES AT:

802 Main Street, Essexville, MI  48732  866-MY-FUSION  info@fusionmedical.com

C. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS.

1. Treatment means the provision, coordination or management of your health care, including consultations between health care providers regarding your care and referrals for health care from one health care provider to another. For example, your primary care physician assigned by your health insurance carrier, who coordinates all of your general health care, may need to know your history of urinary tract infections which is maintained by your urologist. Therefore, your primary care physician (PCP) may review your medical records to assess whether you have potentially complicating conditions and to appropriately order treatment and medical supplies.

2. Payment. Fusion Medical Supply may use and disclose your identifiable health information in order to bill and collect payment for the items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your medical supplies. We also may use and disclose your identifiable health information to obtain payment from third parties that may be responsible for such costs. Also, we may use your identifiable health information to bill you directly for items.

3. Health Care Operations means the support functions of our business related to treatment and payment, such as quality assurance activities, case management, receiving and responding to complaints, compliance programs, audits, and other administrative activities.

4. Reminders to you about your shipments or supplies may disclose your identifiable information.

D. USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN CIRCUMSTANCES

1. Disclosures Required by Law. Fusion Medical Supply will use and disclose your identifiable health information when we are required to do so by federal, state or local law.

2. Health Oversight Activities. Fusion Medical Supply may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil,, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

4. Lawsuits and Similar Proceedings. Fusion Medical Supply may use and disclose your identifiable health information in response to a court or administrative orders, if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

5. Workers’ Compensation. Fusion Medical Supply may release your identifiable health information for workers’ compensation and similar programs.

6. Product Alternatives. Fusion Medical Supply may use and disclose medical information to tell you about or recommend possible medical supply options or alternatives that may be of interest to you.

7. Health-Related Benefits and Services. Fusion Medical Supply may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

8. Individuals Involved in Your Care or Payment for Your Care. Fusion Medical Supply may release medical information about you 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 your condition and that you are in the hospital. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

9. Research. Under certain circumstances, Fusion Medical Supply may use and disclose medical information about you for research purposes.

10. To Avert a Serious Threat to Health or Safety. Fusion Medical Supply may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

11. Military and Veterans. If you are a member of the armed forces, Fusion Medical Supply may release medical information about you as required by military command authorities. 

12. Public Health Risks. Fusion Medical Supply may 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 births and deaths

·         to report child abuse or neglect

·         to report reactions to medications or problems with products

·         to notify people of recalls of products they may be using

·         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.

13. Law Enforcement. Fusion Medical Supply may release medical information if asked to do so by a law enforcement official:

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

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

·         About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement

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

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

14. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, Fusion Medical Supply may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

E. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION

You have the following rights regarding the identifiable health information that we maintain about you:

1. Confidential Communications. You have the right to request that Fusion Medical Supply communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a confidential communication, please specify the requested method of contact, or the location where you wish to be contacted. Fusion Medical Supply will accommodate reasonable requests. You do no need to give a reason for your request.

 

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your identifiable health information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure or your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to our request; however, if we do agree, we are bound by our agreement except when otherwise required by law. In order to request a restriction in our use or disclosure of your identifiable health information, you must make your request in writing to the Fusion Medical Supply Privacy Compliance Officer. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our company’s use, disclosure or both; and (c) to whom you want the limits to apply.

 

3. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records. You must submit your request in writing to the Fusion Medical Supply Privacy Compliance Officer, in order to inspect and/or obtain a copy of your identifiable health information. Fusion Medical Supply may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Fusion Medical Supply may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.
   
   
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to the Fusion Medical Supply Privacy Compliance Officer. You must provide us with a reason that supports your request for amendment. Fusion Medical Supply will deny your request if you fail to submit your request (and the reason supporting the request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for Fusion Medical Supply; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by Fusion Medical Supply, unless the individual or entity that created the information is not available to amend the information.

 

5. Accounting of Disclosures. All of our clients have the right to request an “accounting of disclosures”. An “accounting of disclosures” is a list of certain disclosures Fusion Medical Supply has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to the Fusion Medical Supply Privacy Compliance Officer. All requests for an “accounting of disclosures” must state a time period which may not be longer than six years and may not include dates before January 01, 2004. The first list you request within a 12 month is free of charge, but Fusion Medical Supply may charge you for additional lists within the same 12 month period. Fusion Medical Supply will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
   
   
6.  Right to a Paper Copy of this Notice. You are entitled to receive a copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Fusion Medical Supply Privacy Compliance Officer.
    
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with Fusion Medical Supply or with the Secretary of the Department of Health and Human Services. To file a complaint with Fusion Medical Supply, contact the Fusion Medical Supply Privacy Compliance Officer at Fusion Medical Supply. All complaints must be submitted in writing. To file a complaint with the Secretary, please contact: Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201 OCR Hotlines-Voice: 1-800-368-1019 You will not be penalized for filing a complaint.
   
   
8. Right to Provide an Authorization for Other Uses and Disclosures. Fusion Medical Supply will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note, we are required to retain records of our services.

 

 

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA PRIVACY POLICY PRACTICES:

(Upon receipt of this Notice of Privacy Policy Practices please sign and

return this section only, to Fusion Medical Supplies, LLC . Please retain the booklet for your files.)

 

I hereby acknowledge that I have received a copy of Fusion Medical Supplies Notice of Privacy Policy Practices.

 

Signed_____________________________ Date______________________

 

If the patient is unable to sign and return this Acknowledgement due to a physical or mental condition or legal incapacity, it may be executed by the patient’s legal representative. In such case, the legal representative should fill out the following:

 

Patient’s Name_____________________________   Date _____________________

 

 

AUTHORIZATION TO SUBMIT INFORMATION AND CLAIMS TO INSURANCE CARRIER:

(In order to bill your insurance company for products and services, we must have your consent.)

 

I authorize payment directly to Fusion Medical Supplies for products and services related to my claim.

 

Signed_____________________________ Date______________________

 

AUTHORIZATION TO RELEASE MEDICAL INFORMATION:

 

I authorize the release of medical information or other pertinent information necessary to complete and process this claim.

 

Signed_____________________________ Date______________________