This notice describes how medical information about you may be used and disclosed and how you can get access to the information. Please review it carefully.

Image North ~ Advanced Radiology Specialists has adopted the following privacy policies.

Uses and Disclosures

Treatment – Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of
radiology tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment – Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information and dates of service, the services provided, and the medical condition being treated.

Health care operations – Your health information may be used as necessary to support the day-to-day activities and management of Image North. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law enforcement – Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public health reporting – Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization – Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Image North’s Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by amendments in federal and state laws and regulations. If and when we are notified of these revisions, we will provide you with a amend notice on your next imaging center visit. The revised polices and practices will be applied to all protected health information that we maintain.

Authorization for Phone Calls

I authorize the staff of Image North to call my home, work, or cell phone number regarding office appointments and/or procedure information.

I authorize the staff of Image North to leave a message on my voice mail or telephone recorder regarding office appointments and/or procedure information.

Complaints / Contact Person

If you would like to submit a comment or complaint about our privacy practices, or if you believe that your privacy rights have been violated; you should call the matter to our attention by sending a letter outlining your concerns to:

Carrie Kenoe
Image North
2922 D & M Drive
Gaylord, MI 49735

You will not be penalized or otherwise retaliated against for filing a complaint.

Expiration Date of Authorization

This authorization is valid for five (5) years from date of signature unless revoked or terminated by the patient or patient’s personal representative.

Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to Image North. You should contact the Office Administrator to terminate this authorization.