HIPAA Notice of Privacy Practices

**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**

The Agency maintains a medical record (paper/electronic file) of the information we receive and collect about you and of the care we provide to you. This record includes physician orders, assessments, medication lists, clinical progress notes and billing information. All of this information is referred to as “Protected Health Information,” or PHI for short. Our Agency is required by law to maintain the privacy of PHI and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of PHI (pursuant to 45 CFR 164.520). We will use or disclose this information only in a manner that is consistent with this notice. We will let you know promptly if a breach has occurred that may have compromised the privacy or security of your information.

As required by law, we maintain policies and procedures about our work practices, including how we provide and coordinate care provided to our patients. As our patient, information about you must be used and disclosed to other parties for purposes of treatment, payment and health care operations. Examples of reasons why information may be disclosed include the following:

  • Treatment: Providing, coordinating or managing health care and related services; consultation between health care providers relating to a patient or referral of a patient for health care services from one provider to another.
  • Payment: Billing and collecting for services provided; determining plan eligibility and coverage; precertification; medical necessity review.
  • Health Care Operations: General Agency internal administrative and business functions; quality assurance/improvement activities; medical & utilization review; auditing functions; developing clinical guidelines; determining the competence or qualifications of health care professionals; evaluating Agency performance; conducting training programs with new employees; survey, certification, accreditation and credentialing activities; certain marketing activities.

The above uses and discloses do not require your consent, and include, but are not limited to, a release of information contained in financial/medical records, including information concerning communicable diseases such as HIV, AIDS, drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress, or any other related information. This information may be released to the following parties:

  • Your insurance company, self-funded or third-party health plan, Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services;
  • Any person or entity affiliated with or representing us for purposes of administration, billing, and quality and risk management;
  • Any hospital, nursing home or other health care facility to which you may be admitted;
  • Any assisted living or personal care facility of which you are a resident;
  • Any physician providing care to you, or to other health care providers for treatment;
  • Licensing and accrediting bodies;

In addition to the above instances, we are also permitted to use or disclose information about you without your consent or authorization in the following circumstances:

  • In emergency treatment situations, if we attempt to obtain consent as soon as practicable after treatment;
  • Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred from the circumstances;
  • Where we are required by law to provide treatment and we are unable to obtain consent;
  • Where the use or disclosure of medical information about you is required by federal, state or local law;
  • Certain judicial administrative proceedings or for law enforcement purposes;
  • To coroners, medical examiners, and funeral directors;
  • For certain research purposes;
  • To avert a serious threat to public health and safety;
  • For specialized government functions;
  • For Worker’s Compensation purposes

We are permitted to use or disclose information about you without your consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:

  • Development of a directory of individuals served by our Agency
  • To a family member, relative, friend, or other identified person, if the information is relevant to such person’s involvement in your care or payment for care; to notify a family member, relative, friend, or other identified person of the individual’s location, general condition or death.

Please let us know if you have certain preferences regarding how we share this information. Other uses and disclosures will be made only with your written consent. That consent may be revoked, in writing, and any time, except in limited situations.

You have the right to:

  • Request restrictions on uses and disclosures of your protected health information. We will make every effort to honor such restrictions, but we are not required to agree to a requested restriction. If you have paid out-of-pocket in full for a particular item or service, we will honor your request to not share that information with your health insurer.
  • Receive confidential communication of protected health information.
  • Inspect and obtain copies of protected health information. We may charge a fee for this, to cover our costs, and will provide the record within 4 days or at your next home visit.
  • Request to amend protected health information. We may not agree to do this, but we will respond in writing to your request within 60 days.
  • Receive an accounting of disclosures of protected health information.
  • Obtain a paper copy of this notice at any time, even if you have agreed to receive it electronically.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise these rights and make choices about your health information. We will make sure that person has the proper authority and can act for you prior to taking any action.

This notice is effective 9/28/2017. If you believe that your privacy rights have been violated, you may complain to us or to the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation against you for filing a complaint. For further information regarding filing a complaint, or for further information about matters in this notice or the Agency’s privacy policies, please contact:

Total Knee Accelerated Recovery DME, LLC Attn: Director of Operations

32800 Franklin Rd

Franklin, MI 48025

Phone: (248) 550-0471

By signing the consent to treat form, you agree to these privacy terms and acknowledge receiving a copy of them.


Your complaints or problems are important to Total Knee Accelerated Recovery DME, LLC. We will give full consideration to any problem or complaint and will make an effort to resolve the issue in an agreeable manner. We assure you, that you will have the opportunity to voice grievances and recommend changes in services and/or policies without discrimination, coercion, unreasonable interruption of services or reprisal in any manner from the Organization. If you have a complaint, please:
1. Submit the complaint either verbally or in writing to the Director of Operations, who can be reached at (855) 910-5633 ext 105.2. The Administrator will contact you or your representative and will make every effort to resolve the complaint to your satisfaction.3. If the complaint cannot be resolved to your satisfaction, you may request that the Administrator submit your complaint to the Organization’s Board of Directors.