Michigan Pediatric Surgery Associates, PC, (MPSA), understands that medical information about you and your health is personal and we are committed to protecting this information. We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices.

All personal and medical information collected by MPSA will be regarded as confidential and will not be used or released to any third party with the following exceptions:

  • Release to other health care providers, such as your primary care physician or radiologist, when such information is material and necessary to your treatment
  • Release to your insurance company when such information is necessary for payment for services provided by MPSA
  • Use for normal healthcare operations such as calling you by name in the waiting room, internal or external auditing, appointment reminders and information regarding our services
  • Release when required by law such as subpoena or court order.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to MPSA will be made only with your written permission (or, in the case of minors, parent or legal guardian’s permission). If you provide us with written authorization to disclose information about you, this authorization may be revoked at any time by contacting the Privacy Officer with a written request.

MPSA will take reasonable precautions to ensure that confidential patient information is not accidentally or inadvertently disclosed, that medical records are maintained in a secure environment, that access to computerized information is restricted and electronic transmission of patient information is performed in a secure manner.

MPSA will not sell, trade or otherwise share listings of patient names, address or other confidential information, nor will it engage in any marketing, advertising or public relations activities which would involve the release of confidential medical or personal information, unless the patient has signed an authorization form specifically allowing us to do so.

MPSA physicians are engaged in the teaching of medical students, residents and fellows. These individuals are bound by the same privacy standards as the physicians and staff of Michigan Pediatric Surgery Associates.

MPSA may disclose your medical or demographic information to researchers when their research has been approved by an institutional review board and the board has determined that the research meets certain requirements for protection of this information.

MPSA also provides services to our patients through contracts with outside business associates, which would give them access to confidential patient information. Examples of such associates include answering services, computer vendors and transcription services. These associates are held to the same privacy standards as explained above.

You have the following rights regarding medical information we maintain about you:

  • To review and obtain copies of your records (a reasonable fee may be charged for copying)
  • To request restrictions regarding who sees your records (MPSA reserves the right to deny such request)
  • To confidential communication
  • To request amendments to your records
  • To receive an accounting of all disclosures other than for treatment, payment and healthcare operations.

Michigan Pediatric Surgery Associates reserves the right to revise this notice at any time. The new notice will apply to all confidential information we maintain at that time. The Notice of Privacy Practices in effect will be posted at the registration desk at each of our offices. You may request a copy at any time by asking the receptionist or contacting the Privacy Officer at 313-831-3220. If you believe your privacy rights have been violated, you may file a complaint with us by notifying the Privacy Officer. MPSA will not retaliate against you for filing a complaint.

All complaints must be submitted in writing:

Michigan Pediatric Surgery Associates, PC
ATTN: Privacy Officer
PO Box 36605
Detroit, MI 48201

You may also file a complaint with the Secretary of Health and Human Services.