Privacy Officer Contact Information: 734.390.9009 [email protected]
Effective Date of Notice: 11/15/2024

NOTICE OF PRIVACY PRACTICES 1

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.

Your Rights

You have the right to:

• Receive an electronic or paper copy of your medical record
• Correct your medical record or health information
• Request confidential communications
• Ask us to limit information we use or share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
  

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Market our services
• Raise funds
  

Our Uses and Disclosures

We typically use and share your information in the following ways:

• Treat you: use and share your health information with other professionals treating you
• Run our organization: to improve your care and contact you when necessary
• Advertising and promotion: we may use your story and ultrasound images with all identifying
  information removed or de-identified to protect your privacy
• Help with public health and safety issues such as:
  o Preventing disease, helping with product recalls or reporting adverse reactions to medications
  o Reporting suspected abuse, neglect, domestic violence, or reducing a serious threat to anyone’s
  health or safety
• Do health research
• Comply with state or federal laws requiring sharing of information, including with the Department of
  Health and Human Services to ensure we’re complying with privacy laws.
• Respond to lawsuits and legal actions: in response to a subpoena, court or administrative order

Your Rights

When it comes to your health information, you have certain rights, explained here:
Receive an electronic or paper copy of your medical record and other health information we have about you

• Ask us how to see or get an electronic or paper copy of your medical record
• We will usually provide this within 30 days of your request and may charge a reasonable, cost-based
  fee.
  

Correct your medical record or health information about you that you think is incorrect or incomplete

• Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• Ask us to contact you in specific ways (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Ask us to limit information we use or share
• Ask us not to use or share certain health information for treatment or our operations. We are not
  required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared your information

• Ask for a list (accounting) of the times we’ve shared your health information for six years prior to the
  date you ask, who we shared it with, and why.
• We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• Request a paper copy of this notice at any time, even if you have agreed to receive the notice
  electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you believe your privacy rights have been violated

• You can complain if you feel we have violated your rights by contacting us.
• You can file a complaint with Sienna Women’s Health by sending a letter to 840 Maus Avenue, Ypsilanti, MI 48198 or calling 734-390-9009.
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear
preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
  If you are not able to tell us your preference, for example, if you are unconscious, we may share your
  information if we believe it is in your best interest. We may also share your information when needed to
  lessen a serious and imminent threat to health or safety.
  In these cases, we never share your information unless you give us written permission:
• Marketing purposes
  In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Responsibilities:

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security
  of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
  writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you
  change your mind.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, in our office, and on our website.

Notice of Privacy Practices Acknowledgement

Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies: 1)
how medical information about you may be used or disclosed; 2) your rights to access your medical
information, amend your medical information, request an accounting of disclosures of your medical
information, and request additional restrictions on our uses and disclosures of that information; 3) your
rights to complain if you believe your privacy rights have been violated; and 4) our responsibilities for
maintaining the privacy of your medical information.

The undersigned certifies that he/she has read the foregoing, received a copy of the Notice of Privacy
Practices and is the patient, or the patient’s personal representative.