This notice is provided to you in compliance with the Health Insurance Portability and Accountability Act of 1996. 


The medical information that you give us about yourself and that we keep on file (either in written form or electronically) may be used for any of the following purposes:

  • To help us to treat your medical condition or recommend preventive measures, such as prescribing the right medication or not prescribing things that you are allergic to.
  • To assist us in receiving payment for our services from you, your employer, your insurance company or other appropriate parties.
  • To report certain infectious diseases to public health authorities as required by law.
  • To perform internal audits in order to make sure that our medical practices and recommendations are up to date and appropriate.
  • To perform research on diseases and health conditions in order to improve diagnosis and treatment.

In order to accomplish these purposes, we may need to provide some of your medical information to people or organizations outside of our office, including but not limited to:

  • Members of your family
  • Other medical providers such as your primary care physician, specialists to whom we refer you, radiologists and medical laboratories.
  • Our answering service, medical transcriptionist or other such people who help us render good medical care to you.
  • Your insurance company, employer, or whoever pays your medical bills.
  • Public health authorities, law enforcement agencies and other government entities as required by law.
  • Statisticians who assist us in our research and internal audits.
  • The Red Cross or other such service agencies in the case of emergency.

Sometimes, in order to confirm appointments, report your laboratory findings or recommend treatment, we may need to contact you at home or at work.  This may involve sending you a letter or e-mail, sending a fax or leaving a message on your answering machine.

You, as our patient, have certain rights related to your medical information.  These include:

  • The right to request that we NOT give your medical information to certain people or organizations, such as specific family members or your family doctor.  Such a request will need to be in writing and we will inform you as to whether or not we are able to honor the request.
  • The right to request that we NOT contact you by a certain method or at a certain place, such as by telephone at work.  In this case, you will need to provide us in writing with a reliable means of contacting you.
  • The right to see and have a copy of all the information we have about you, except where such a disclosure is prevented by law or if we feel that providing the information would be harmful to you.  (For instance, if you are involved in a lawsuit the conditions imposed by the court may forbid us from giving you a copy of information pertinent to the lawsuit.  Or if, in our medical judgment, telling you a laboratory result would reduce our ability to help you get well.)
  • The right to appeal to another licensed medical professional if we do not provide you with a copy of the information you request.
  • The right to NOT tell us why you want your medical information kept from  certain people or sent by certain methods.
  • The right to ask to amend your medical record if you feel it is not accurate.
  • The right to have placed in your file a written statement saying that you disagree with the medical record, even if we deny your right to amend the record.  Either an amendment or such a written statement must be limited to 3000 words or 10 pages, whichever is shorter.
  • The right to have a complete list of everyone to whom we have released medical information about you in the past six years for anything but the usual medical purposes.  Usual medical purposes include:
    • Providing your medical treatment
    • Medical transcription and otherwise operating our office efficiently
    • Sending information directly to you
    • Sending information that you asked us to send to others
    • Sending information as required by law to public health authorities or other government entities
    • Billing
  • Such a list will include the name and address to which we sent the information, the date it was sent, what information was sent and why it was sent.

Our rights and responsibilities as your medical provider include:

  • The responsibility to protect by every reasonable means the privacy of your medical information.
  • The responsibility to respond within 30 calendar days to any request that medical records to be sent to you or to another party.
  • The responsibility to respond to your request for an amendment within 60 days of when we receive the request.
  • The right to deny your request for limitations on to whom we release your medical information if, for medical, legal or financial reasons, we feel that we must reveal this information.
  • The right to insist that your request that we not contact you by certain means does not make it too difficult for us to contact you at all.
  • The right to choose the medical provider to whom your appeal is sent, as long as that provider is not involved in your health care.
  • The right to refuse to amend your medical record if
    • we did not create the original record (for instance, if what you want to amend is a record we received from another physician),
    • what you want us to amend is not really part of your medical record
    • what you want us to amend is not available for us to inspect (such as a letter or laboratory report that is in the possession of another doctor)
    • if we believe the record is accurate and complete the way it stands.
  • The right to charge a reasonable, cost-based fee for providing any requested medical information to you or to other parties.  Also, if you request a list of places where we sent your medical information, the first list in a twelve-month period is free, but after that the same fee rate will apply as would a request for medical records.

If you feel that we have inappropriately disclosed information about you, or you wish to make a complaint about how your medical information has been handled, we encourage you to promptly contact our Office Manager by writing to us at 17720 Cobblefield Lane Spring Lake, MI 49456 or by telephone at 1.877.TRAVDOC.

In addition, there is a government office to which you may address complaints.  The address for this is:

Region V, Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240, Chicago, Ill. 60601.
Voice Phone (312) 886-2359
FAX (312) 886-1807
TDD (312) 353-5693

This notice is effective as of April 14, 2003