date: welcome to bronson lakeview family care

Date: ________________

Dear__________________________

Welcome to Bronson LakeView Family Care – Internal Medicine. Thank you for choosing us for your Healthcare

needs. Enclosed is our brochure outlining our guidelines. Also, there is paperwork for you to complete and bring

with you to your appointment.

Health History Form

Please fill out the enclosed Health History form and bring it to your first appointment on ____________________.

It is important ___________________________ have a complete record of your medical history to make informed

decisions about your care and treatment options. If this is not complete when you arrive for your first visit, you

may need to reschedule your appointment.

Consent for release of information

You will also need to complete the enclosed authorization for release of information. You will need to mail it to

your previous doctor as soon as possible. This will allow us to obtain your medical records for _________________

to have available for your first visit.

Appointment Billing

____________________________ feels it is important for your health to complete a physical exam. Please be

aware that many insurance companies do not cover routine or preventative services. This visit may be billed as a

routine service and submitted to you insurance company as a routine service.

It is strongly recommended that you contact your insurance company prior to receiving these services to verify

your insurance coverage. Please be aware if your insurance company does not pay for these services, you will be

responsible for payment.

It is very important you bring your insurance card(s) to each visit so that we may submit a bill to your insurance

company for you. Please be prepared to pay any copays or deductibles.

Additional Forms

Registration Forms

Financial Policy

Bronson LakeView Medical Practices Authorization to Treat (If applicable)

Parental Minor Consent form (if applicable)

Advance Directive

HiPPA – Notice of Privacy Practices

Diagnostic Use of Authorization Form

Testing

If you have an early morning appointment, you may wish to fast for 12 hours (nothing to eat or drink except water)

before your appointment. This way, if ___________________ would like you to have fasting lab work done, you

may do that while you are here and save yourself an extra trip. If you are not fasting or have a later morning or

afternoon appointment, you can return to the lab for your blood work at another time.

An EKG may be performed during your visit, Please do not use any body lotions or creams on the day of your

appointment.

Emergency & After Hours Calls

A Provider is on-call at all times to help with emergencies. If you feel your emergency is a matter of life or death,

call 911 or go to the nearest emergency room. If you have an urgent need after hours, please call our office and

you will be directed to a triage nurse. The nurse may provide advice, schedule an appointment or direct you to

seek emergency care.

Bronson MyChart

Bronson MyChart is a free and secure way to look at parts of your medical record on your computer. You can

review prescriptions, send messages to your Doctor or a member of our staff and schedule routine appointments.

Ask our staff to set up your MyChart account.

Arrival Time

If you are unable to make your new appointment, Please contact us at least 24 hours in advance. If you fail to

inform us that you cannot keep your new patient appointment, then the providers at Bronson LakeView Family

Care – Internal Medicine may not see you as a patient.

Please arrive 15 minutes before your scheduled appointment time to complete the registration process. Patients

arriving late may need to reschedule.

If you have any questions, please feel free to contact our office at 269-655-3080. We look forward to seeing you at

you appointment.

Sincerely,

Bronson LakeView Family Care – Internal Medicine

of 2

LakeView

Request for Access or Authorization for Use and Disclosure of Protected Health Information

Patient Name: _____________________________________________________________________ Last First MI Date of Birth: _________________________________ Month Day Year

I give permission to Bronson Medical Practices to use or disclose my protected health information indicated below to

Physician to release records:

Name_________________________________

Address:_______________________________

__

Phone __

Fax __

Physician/Person to receive records:

Bronson Lakeview Family Care-Internal Medicine

451 Health Pkwy Suite F

Paw Paw, MI 49079

Phone: (269) 655-3080

Fax: (269) 655-0761 Attn:_____________________________ Information to be released:

(Please check boxes that apply)

Discharge Summary

History and Physical Exam

Progress Notes

Lab Reports

X-Ray Reports

Medication Records

Detailed Bill

Other (specify content and dates) ______________________________________________________

Purpose of Disclosure:

Changing doctors

Consultation

Insurance or Workers’ Compensation

School

Research

At request of individual

Legal (specify) _______________________________________________________________

Other (specify) _______________________________________________________________

For my own use

of 2

I authorize the release of health information, contained in my medical records including:

Information regarding communicable diseases and infections, as defined by statue and Michigan

Department of Health rules, which include venereal disease, Tuberculosis, Hepatitis A, B, C,

Human Immunodeficiency Virus (HIV), HIV testing.

Acquired Immunodeficiency Syndrome (AIDS) and AIDS related complex (ARC).

Alcohol and drug abuse treatment information protected under the regulations in CFR 42, Part 2.

Mental health treatment records, psychological services and social services information including

communications made by me to a social worker, therapist, or psychologist.

Acknowledgement of Understanding:

I understand this authorization will expire in one year from date signed.

I can cancel this authorization at any time by writing to Bronson Medical Group.

It will take effect on the date notified, except if action has already been taken.

I understand that if I release my medical record to a person or provider, they can release my

medical record. I know I need to check with them about their privacy rules.

I will get an abstract of my medical record unless I ask for the complete record.

No conditions will be placed on me if I sign this form.

Michigan law says I may have to pay for:

Copies of my record

Inspection of my record

Written summary of findings

Bronson Medical Practices will not benefit from disclosing this information.

____________________________________________________ ___________________________

Signature of Patient Date

____________________________________________________ ___________________________

Parent or Personal Representative Date

Revised 8/2011 Page 1 of 2

319 W Delaware, Decatur, MI 49045 (269) 423-7028

52375 N Main St, Mattawan, MI 49071 (269) 668-3348

451 Health Parkway, Suite A, Paw Paw, MI 49079 (269) 657-2550

Surgery - 404 Hazen, Suite 101, Paw Paw, MI 49079 (269) 657-4407

451 Health Parkway, Suite B, Paw Paw, MI 49079 (269) 655-3065

Patient Name ________________Date of Birth ________ Date _______________

Marital status: ___ Married ___ Single ___ Widowed ___ Divorced

Do you see other specialists? If yes, then who? __________________________________________________

Race/Ethnicity: ___ Hispanic/Latino ___ White ___ Black/African American ___ Asian

___ Native Hawaiian/Other Pacific Islander ___ American Indian/Alaska Native ___ Other

Preferred Language:_______________________________________________________________________

NEW HEALTH HISTORY FORM (ADULT)

SURGERIES:

IMMUNIZATIONS (list the last time you had): Tetanus/Date: _________________________ TB test Pneumovax Flu shot MMR Hepatitis B Shingles

MEDICATIONS (you are currently taking from all providers): *only needs completed at first new patient visit.

ALLERGIES (list allergies to medicines): _________________________ Latex allergy Y N Have you been hospitalized in the last 3 years? Y N

MEDICAL HISTORY

Have you ever had? Y N Have you had in last year? Y N Have you had in last year? Y N

Cataracts Dizzy spells Extreme fatigue

Glaucoma Numb arm/leg Night sweats

Allergies/sinus Frequent headaches Frequent fevers

Anemia Fainting Frequent sore throats

Asthma Hearing loss Frequent earaches

Pneumonia Vision loss Frequent bronchitis

Hiatal hernia Chest pain Joint pain

Stomach ulcers Shortness of breath Swollen ankles

Thyroid disease Wheezing Foot problems

High cholesterol Cough Recurrent rashes

Diabetes Loss of appetite Moles (new size/color)

High blood pressure Indigestion Dental exam

Heart murmur Heartburn Eye exam

Irregular pulse Frequent diarrhea

Palpitations Frequent constipation Childhood Diseases (check if you had): Heart disease Bloody stools

Head injury Tarry stools Chicken pox

Seizures Rectal itching Tuberculosis

Depression/anxiety Urinary infections Mumps

Kidney disease/stones Blood in urine Rubella

Colon polyps/colitis Frequent urination Rheumatic fever

Cancer Sudden weight loss (> 10 lbs) Polio

Osteoporosis

Patient Name _________ Date of Birth ____________ Date_____________________

Revised 8/2011 Page 2 of 2

MEN: Problems with urination? Y N Prostate trouble? Y N Last prostate check & blood test ___________________

Do you perform testicular exams? Y N Discharge from penis? Y N Impotence? Y N

Circle if you have had: Hernia Hepatitis Herpes HIV Transfusion WOMEN: Total number of times pregnant___________ Are you nursing? Y N Number of living children________________ Any abnormal pap smears? Y N Number of miscarriages/abortions_________ Any breast disease? Y N Date of last mammogram________________ First day of your last period______________ Date of your last pap test________________ Circle if you have had: Herpes Hepatitis Frequent yeast Transfusion HIV SOCIAL HISTORY: Occupation ______________________________________________________ Do you wear a seatbelt? Y N Do you drink coffee/tea/soda? Y N How many cups/day Do you drink alcohol? Y N How many drinks/day Do you smoke/chew/use tobacco? Y N How many packs/day Have you used street drugs? Y N Which ones __________________________________________ Do you wear sunscreen? Y N FAMILY HISTORY:

Moth

er

Fath

er

Bro

thers

Sis

ters

Mate

rnal

Gra

ndm

a

Mate

rnal

Gra

ndpa

Pate

rnal

Gra

ndm

a

Pate

rnal

Gra

ndpa

Aunts

Uncle

s

Allergy/sinus

Asthma

Breast cancer

Cancer (other)

Colon polyps/colitis

Diabetes

Heart disease/attacks

High blood pressure

High cholesterol

Thyroid disease

Stroke

Depression/anxiety

Alcohol/drug use

Kidney disease

Tuberculosis

Osteoporosis

This is my important medical history. The doctor will use this information to make medical decisions about me. I am responsible to tell my doctor about my medical history on this form. Patient Signature Date Provider’s Signature Date

9004284-E (2/15) Intranet Equivalent to 9004608-S Bronson Physician Practices Financial Policy Page 1 of 2

*9004284-E*

Patient Name:____________________ DOB:______________

I. 01 Bronson Physician Practices Financial Policy

We are committed to providing you with the best possible medical care. If you have special needs, we are here to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.

Our office participates with a variety of insurance plans. If you are a member of one of these plans, our business office will submit a claim for services. If you have insurance for which we are not a contracted provider, we will bill the insurance as a courtesy. You must assign benefits to the practice so that payment will come directly to the practice. It is your responsibility to:

o Provide us with current insurance and billing information including your Social Security Number, and bring your insurance card to each visit.

o Be prepared to pay your co-pay at each visit. o Pay any balance not covered by your insurance plan including co-pays and deductibles.

Patients with outstanding balances will receive monthly statements. The statements will indicate what, if any, of the outstanding balance is patient responsibility and what is pending insurance payment. Payment of outstanding patient balances is expected within 30 days of receipt of statement. Patient balances over 90 days will be sent to a collection agency.

You agree, in order for us to service our account or to collect any amounts you may owe, we may

contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending a text message or e-mail, using any e-mail address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

Payment for professional services can be made with cash, check or credit card. You may be billed separately for lab, x-ray, pathology and other hospital services. A charge of $25.00 will be assessed for all returned checks and patients will be expected to pay this charge by credit card, money order or in cash upon receipt of a statement.

Specialist Authorizations: It is your responsibility to ensure that any required authorizations for treatment are provided to the practice prior to the visit. If you do not have the authorization, your visit may be rescheduled, or you may be financially responsible.

Primary Care Authorizations: If your primary care physician is not a Bronson Medical Group

physician, you are responsible for obtaining any required authorizations from your PCP or health

plan for treatment prior to the visit. If you do not have the authorization, you may be financially

responsible.

Affix Patient Label

9004284-E (2/15) Intranet Equivalent to 9004608-S Bronson Physician Practices Financial Policy Page 2 of 2

Patient Name:_____________________ DOB:______________

Workers Compensation: If your claim has been accepted and services approved, your claim will be

handled directly with your Workers Compensation carrier and no charges will be incurred by you. Your recovery and return to work takes a partnership with you, your case manager and us. If your claim is denied, charges become your responsibility.

If the patient is a minor (18 years and younger), the parent or guardian must sign below. The parents, guardian or unaccompanied minor is responsible for any payment due at the time of service, bringing the necessary authorization and insurance card.

Some services, such as preventive services, may not be a covered benefit under your insurance plan or under Medicare benefit guidelines. It is your responsibility to pay any balance not covered by your insurance plan.

If you have questions about your insurance, we are happy to help you. Specific coverage issues, however, should be directed to your insurance company member services department (number is on the insurance card).

We reserve the right to charge $25.00 for a cancellation within 24 hours of your appointment or failure to appear at your scheduled appointment time.

Your bill may be amended if errors in billing are found.

Our practice firmly believes that a good physician/patient relationship is based upon understanding and good communication. Questions about financial arrangements and available payment plans should be directed to the physician's office. We are here to help you.

Assignment I authorize release to any third party payor such as an insurance company or governmental agency any medical information contained in my records when such material is required in connection with determining a claim for payment, and hereby assign all payments for medical services for myself and/or dependent to Bronson. I agree to pay for any charges not covered by my insurance.

______________________________ ____________________________ _____________________ Signature of Responsible Party Patient's Date of Birth Date Revised 4/07, 4/09, 11/09, 04/10, 10/11, 4/15

Affix Patient Label

Patient Name: _______________________________

Date of Birth: ________________________________

Adult Consent to Treat

I, ____________________________________________, give permission to the staff of Bronson

LakeView Practices to give me medical treatment. I agree to tell Bronson LakeView Medical

Practices if I have any concerns about my medical treatment at the time of treatment.

Signature Date

*9004405*

Name: ________________________ Date of Birth:_______________

9004405 (8/13) Intranet Authorization to Share Medical Information Page 1 of 1 WH20-5HT

Affix Patient Label

Authorization to Share Medical Information

I authorize Bronson Healthcare Group to share my:

Personal and/or demographic information

Medical information – excluding _____________________________________________________

Billing/financial/insurance information

All information

To the following individuals:

_______________________________ _______________________ __________________________

Name Phone Number Relationship to Me

_______________________________ _______________________ __________________________


_______________________________ _______________________ __________________________


_______________________________ _______________________ __________________________


-OR-

I do not authorize Bronson Healthcare Group to release any of my medical information to anyone, with the

exception of coordination of benefits (i.e., insurance) or continuation of care (i.e., referrals).

This authorization will remain in effect until revoked in writing by the above listed patient.

______________________________________________________ ______________________________

Signature Date

*9004228*

9004228 (3/15) Intranet

Consent

Diagnostic Use Authorization Adult and Pediatric Use

Affix Patient Label

Page 1 of 1

Due to various insurance requirements, it is necessary for us to inform you of

where your diagnostic test will be sent.

The tests may or may not be covered by your insurance plan. If you have any

questions about your insurance coverage, please contact your insurance

company prior to having these tests performed.

I acknowledge that all diagnostic specimens obtained in our office (ex: laboratory,

pathology, cytology etc.) will be sent to Bronson Hospitals for processing.

_________________________________________________________________

Patient Signature Date

Diagnostic Use Authorization

Patient Name:________________Date of birth:___________

9002795-E (07/14) Intranet/Internet Bronson Healthcare Group Notice of Privacy Practice Page 1 of 7 Equivalent to 9002833-S

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.

I. Who We Are

This Notice describes the privacy practices of Bronson Healthcare Group, Inc., and each of its subsidiaries, including, but not limited to, Bronson Methodist Hospital, Bronson Battle Creek Hospital, and Bronson LakeView Hospital (“we” or “us”), including:

All healthcare professionals allowed to enter or access information in your medical record.

All employees and physicians and other health care professionals on the Medical Staff when they provide services in our facilities with access to your medical or billing records or health information about you (“Protected Health Information”).

Any student or volunteer authorized to help you while you are a patient.

Bronson has expanded the use of its electronic medical record system to affiliated partners. A list of affiliated partners may be found on the Bronson web page.

II. Our Privacy Obligations

We understand that your health information is personal and we are committed to protecting your privacy. In addition, we are required by law to maintain the privacy of your Protected Health Information, or “PHI”, to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information, and to notify you in the event of a breach of your unsecured Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. Permissible Uses and Disclosures Without Your Written Authorization

In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your Protected Health Information. However, unless the Protected Health Information is Highly Confidential Information (as defined in Section IV.D below) and the applicable law regulating such information imposes special restrictions on us, we may use and disclose your Protected Health Information without your written authorization for the following purposes:


Treatment. We use and disclose your Protected Health Information to provide treatment and other services to you. We may use and disclose health information to contact you for an appointment reminder, to tell you about health related services or recommend possible treatment options or alternatives that may be of interest to you, to help prepare a research project, to contact you to ask whether you want to participate in a study.

Doctors and other providers who may treat you at places other than Bronson need access to the most complete information possible in order to make treatment decisions about your care. These providers are able to access your electronic and paper records from Bronson for this purpose. For example they may view your medications and test results. If you must leave Bronson for care, your new provider may view your Bronson treatment records. Likewise, when a provider has referred you to Bronson for treatment, they are able to access your electronic record to provide follow up medical care.

Payment. We may use and disclose your Protected Health Information to obtain payment for health care services that we provide to you; for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of your health care (“Your Payor”) to verify that Your Payor will pay for the health care. We may also disclose Protected Health Information to your other health care providers when such Protected Health Information is required for them to receive payment for services they render to you.

Health Care Operations. We may use and disclose your Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality of our services and health care professionals.

Fundraising Communications. We may use certain information (name, address, telephone number, email address, date(s) of service, age, gender and insurance status) to contact you in the future to raise money for our institutionally – related foundation, the Bronson Health Foundation. The money raised will be used to expand and enhance the services and programs that we provide to the community. If you do not want to receive any fundraising requests in the future, you may contact the Bronson Health Foundation at 269-341-8100.

Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if: (1) we obtain your agreement or provide you with the opportunity to object to the disclosure and you do not object; or (2) we reasonably infer that you do not object to the disclosure.


If you are not present for or unavailable prior to a disclosure (e.g., when we receive a telephone call from a family member or other caregiver), we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information under such circumstances, we would disclose only information that is directly relevant to the person’s involvement with your care.

As Required by Law. We may use and disclose your Protected Health Information when required to do so by any applicable federal, state or local law.

Public Health Activities. We may disclose your Protected Health Information: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to a government authority authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

Victims of Abuse, Neglect or Domestic Violence. We may disclose your Protected Health Information if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority authorized by law to receive reports of such abuse, neglect, or domestic violence.

Health Oversight Activities. We may disclose your Protected Health Information to an agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Officials. We may disclose your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

Decedents. We may disclose your Protected Health Information to a coroner or medical examiner as authorized by law.

Organ and Tissue Procurement. We may disclose your Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.


Clinical Trials and Other Research Activities. We may use and disclose your Protected Health Information for research purposes pursuant to a valid authorization from you or when an institutional review board or privacy board has waived the authorization requirement. Under certain circumstances, your Protected Health Information may be disclosed without your authorization to researchers preparing to conduct a research project, for research or decedents or as part of a data set that omits your name and other information that can directly identify you.

Health or Safety. We may use or disclose your Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

Specialized Government Functions. We may use and disclose your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

Workers’ Compensation. We may disclose your Protected Health Information as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.

IV. Uses and Disclosures Requiring Your Written Authorization

For any purpose other than the ones described above in Section III, we only use or disclose your Protected Health Information when you give us your written authorization.

A. Marketing. We must obtain your written authorization prior to using your Protected Health Information for purposes that are marketing under the HIPAA privacy rules. For example, we will not accept any payments from other organizations or individuals in exchange for making communications to you about treatments, therapies, health care providers, settings of care, case management, care coordination, products or services unless you have given us your authorization to do so or the communication is permitted by law.

We may provide refill reminders or communicate with you about a drug or biologic that is currently prescribed to you so long as any payment we receive for making the communication is reasonably related to our cost of making the communication. In addition, we may market to you in a face-to-face encounter and give you promotional gifts of nominal value without obtaining your written authorization.

B. Sale of Protected Health Information. We will not make any disclosure of Protected Health Information that is a sale of Protected Health Information without your written authorization.

C. Psychotherapy Notes. We will not use or disclose psychotherapy notes about you without your authorization except for use by the mental health professional who


created the notes to provide treatment to you, for our mental health training programs or to defend ourselves in a legal action or other proceeding brought by you.

D. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain health information about you (“Highly Confidential Information”), including Alcohol and Drug Abuse Treatment Program records and other health information that is given special privacy protection under state or federal laws other than HIPAA. However, in order for us to disclose any Highly Confidential Information for a purpose other than those permitted by law, we must obtain your authorization

E. Revocation of Your Authorization. You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below.

V. Your Individual Rights

A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your Protected Health Information, you may contact our Privacy Office. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.

B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction unless the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service for which you have paid us out of pocket in full. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.

C. Right to Receive Communications by Alternative Means or at Alternative Locations. You may request, and we will accommodate, any reasonable written request for you to receive your Protected Health Information by alternative means of communication or at alternative locations.


D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we may charge you a reasonable copy fee.

E. Right to Amend Your Records. You have the right to request that we amend your Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from Health Information Management (Medical Records). We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

F. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years. If you request an accounting more than once during a twelve (12) month period, we may charge you a reasonable fee for the accounting statement.

G. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective on July 28, 2014.

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all your Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our waiting room and on our Internet site at www.bronsonhealth.com. You also may obtain any new notice by contacting the Privacy Office.

VII. Privacy Office

You may contact the Privacy Office at: 269-341-8590 or at: [email protected]

Mail may be addressed to:

Bronson Privacy Office

601 John Street, Box 50

Kalamazoo, MI 49007


*9002795*

Please sign below that you have received Bronson Healthcare Group’s Notice of Privacy Practices effective July 28, 2014.

Print Name:

________________________________________________________________________

Date of Birth:_________________________

Signature:

________________________________________________________________________

Date: ___________________________

Relationship if other than Patient: ___________________________________

Witnessed by: ________________________________ Date/Time:___________

Action:

_____ Provided, patient declines to sign

_____ Patient indicates previously signed

_____ Other: ____________________

BRONSON STATEMENT ON PATIENT RIGHTS AND RESPONSIBILITIESBecause Bronson respects the rights and human dignity of eachpatient, patient rights and responsibilities are given upon admission or upon request.

We are committed to making your experience at Bronson aspositive as possible. If you have concerns, complaints, ethical issues or suggestions, please contact the Patient Relations Office at(269) 341-8959.

The Right to Information You Can Understand You have the right to: • Know about Bronson’s policy of Patient Rights and Responsibilities and

Advance Directives • Contact a Bronson Patient Representative if there is a question, concern or

complaint about any service • File a grievance with Patient Relations at (269) 341-8959 or external agency

and to be informed of the procedure for initiation, review and resolution of a grievance or complaint

• Know about services and the charges for services; to have your bill explained; and to know about financial assistance offered at your location

• Know who is giving your care; to information about your health and treatment plan; to know about your future healthcare needs; and the right to be involved in healthcare plans

• Agree to or refuse treatment; to be told the risks of treatment; and the right to be told what will happen if you refuse treatment; and know about Bronson’s rules that affect patient care and conduct

• Receive visitors that you designate, including, but not limited to, a spouse, a domestic partner (including the same-sex domestic partner), another family member, or a friend. You also have the right to withdraw or deny such consent at any time.

• Language assistance services

The Right to Dignified, Respectful, Considerate CareYou have the right to: • Care regardless of age, race, color, creed, national origin, sex, religion, marital

status, sexual orientation, gender identity, disability or your ability to pay for care • Be free from mental or physical mistreatment; be free from restraints unless ordered

by a physician for your safety or the safety of others. If restraint is used, the least restrictive method will be used and it will be stopped as soon as possible.

• Free, reasonably prompt interpreter services during all aspects of your visit to Bronson. Bronson provides interpreter service for limited English proficient patients, deaf/deaf-blind/hard-of-hearing patients and families.

The Right to a Reasonable Response to Your RequestsYou have the right to: • Have a reasonable response to your needs for treatment and service within

Bronson’s ability • Request generic or trade brand drugs • Have your civil and religious rights and your cultural and spiritual beliefs

respected to the extent that they do not interfere with the well being of others

The Right to Personal Privacy and Confidentiality of Your Medical Treatment and Medical RecordsYou have the right to: • Have your personal and medical records treated with privacy; to review your

medical record; and to obtain a copy of your medical record. Your record cannot be given to anyone without your permission, unless required by law, third party payment contract, or accrediting agency.

• Talk privately with your physician, attorney or other person • Send and receive unopened personal mail • Be treated in private; to be cared for with dignity and as an individual.

The Right to be Informed of Any Research or EducationalProjects Affecting Your Care or TreatmentYou have the right to: • Information about experimental treatment considered in your care; and to

know the risks and possible result of refusing this treatment • Be informed if you are part of an educational project as Bronson is a

teaching environment.

Patient Responsibilities Which Will Promote a True Partnership in Your Treatment: • Make available a complete and correct medical history • Let us know if you understand your medical treatment • Take part in healthcare decisions with the advice of your doctor(s) and

follow the recommendations and advice of your doctor(s) • Tell your doctor or nurse about any problems you have during your

medical treatment • Be considerate of the rights of other patients, Bronson staff,

and property • Give correct information about how you will pay your bill • Make arrangements to pay bills not paid by your insurance • Follow Bronson’s rules about patient care and conduct

Bronson Statement on Pain ManagementWe believe all patients have a right to pain relief. Based on this belief we will: • Tell patients that pain relief is an important part of their care • Review patient’s pain on the first evaluation • Continue to look at the presence, quality and intensity of pain • Consider pain monitoring the fifth vital sign and monitor pain often based

on the patient’s condition and pain state • Use what the patient says about their pain as the primary indicator of pain • Accept with respect the reports a patient makes about pain • Respond quickly to reports of pain • Consider the special needs of children, frail and elderly patients in the

assessment and treatment of pain • Work with the patient, family and other healthcare providers to establish

a goal for pain relief • Develop and use a plan to make pain relief the goal, including education

of the patient and family • Continue to review and change the care for patients who have pain that

will not stop.

If your concern is not resolved through Bronson, you may file a complaint via:

0528 0915

The Joint CommissionOffice of Quality MonitoringOne Renaissance BoulevardOakbrook Terrace, IL 60181(800) 994-6610(630) 792-5636 faxEmail: [email protected]

KEPRO Rock Run Center, Suite 100 5700 Lombardo Center Drive Seven Hills, OH 44131(855) 408-8557(844) 834-7130 faxkeproqio.com

Michigan Department of Community HealthBureau of Health ServicesComplaint Investigation UnitP.O. Box 30664Lansing, MI 48909(800) 882-6006michigan.gov/mdch

Ask your caregiver for a copy of the Bronson Statement on Patient Rights and Responsibilities.

Pídale a su cuidador una copia de la Declaración de derechos y responsabilidades del paciente de Bronson.

Preventing Falls

What is my main problem?

I am at risk for falling which could cause injury. Many medical conditions put people at higher risk for falls. I

have one of these conditions, or maybe something different puts me at risk:

Two or more falls in the past six months

Vision loss

Foot pain or shoe problems

Medications that may make me dizzy,

drowsy, or cause low blood pressure

Problem with walking or balancing

Recent surgery

Decrease in muscle strength

High or low blood pressure

Changes in urine or bowel habits

Depression

Dizziness

Male

New environment

What do I need to do? I need to look for things in my home that may cause a fall, and make my home safer. Some things to check:

Lights:

Use good lighting. Have light switches within easy reach.

Keep a small night light on in case you need to get up at night.

Replace burned out bulbs. Lampshades or frosted bulbs can reduce glare.

Stairs:

Use handrails on both sides of the stairs. Make sure handrails are tight and as long as the stairs.

Fix loose or uneven steps.

If the stairs have carpet, make sure it is firmly attached to each step. If the stairs are not carpet, attach

non-slip rubber treads on the stairs.

Paint a different color on the top front edge of each step.

Floors:

Use nonskid mats, especially on floors that may get wet.

Remove small rugs. Tack down the edges of rugs.

Repair or remove torn or loose carpet.

Remove cords or wires on the floor.

Remove clutter.

Do not use floor wax.

Clean up spills right away.

Furniture:

Arrange furniture so that it is not in the way.

Have furniture at the proper height to make it easy to get in and out.

Have furniture that is sturdy and gives support.

Do not use furniture polish spray. Spray that gets on the floor may make floors slippery.

Bedroom:

Place a lamp, flashlight, and batteries where they can be reached from the bed.

Keep bed at proper height to make it easier to get in and out.

Use non-skid slippers with closed backs.

Sit at the edge of the bed for a few minutes before standing up.

Preventing Falls (11/2014)

Bathroom:

Install grab bars in the tub, shower and around the toilet.

Use non-skid mats in tub, shower and floor.

Keep towels and equipment in reach.

Consider using an elevated toilet seat and a tub bench.

Use handheld shower nozzle.

Kitchen:

Keep frequently used items at the front of cupboards or drawers.

Have stove controls within easy reach.

Storage:

Store food and regularly used items where they can be found easily. Avoid reaching for items.

Use a steady step stool with a hand bar if you must reach high. Never use a chair as a step stool.

Outdoors:

Repair cracked sidewalks.

Trim shrubs along path to home.

Install good lighting by doorways and path to doors.

Telephone:

Keep the phone within easy reach at all times.

Keep emergency numbers in large print near each phone.

Put a phone near the floor in case you fall and can’t get up.

Clothing and shoes:

Do not wear clothing that is long enough to trip over.

Wear shoes or non-skid slippers with closed backs and good support.

Do not wear shoes with thick soles.

Children and Pets:

Watch for children and pets underfoot.

Watch for toys or spilled pet food.

Diet and Exercise:

Drink enough liquids to prevent dizziness.

Eat a diet rich in calcium and vitamin D to keep bones strong.

Maintain a healthy weight.

Exercise can increase muscle strength, balance and coordination. Some examples might be walking,

water aerobics and Tai Chi.

Preventive Health:

Consider wearing a device that will bring help in case I fall.

Have my eyes checked every year.

Talk with a doctor or pharmacist about medicine side effects that may increase risk for falls.

Take care of my feet. Foot pain or other foot problems can lead to a fall.

Use a walker or cane when moving around.

Why is this important to me? At least half of all falls happen at home. Each year, thousands of people are seriously hurt, disabled, or die

from a fall. I can take these simple steps to make my home safer so I do not fall.

It’s OK to Ask

Please ask questions and talk with your doctors, nurses and other care providers

during your office visit. Talking together helps make sure you and your family member get the best care possible. There are several areas that Bronson would

like you to pay close attention to:

Medications

o Bring a list of all your medicines, over-the-counter drugs, herbal supplements and vitamins to your appointments every time.

o Ask your doctor for your medication refills during your office visit. This

will help make sure you take your medication without any breaks. o Tell your doctor and nurse about your allergies.

o Ask your doctor about each drug she prescribes and what it is used

for. Make sure the doctor writes the name of the drug clearly so you and the pharmacist can read it. Ask to take home written information

on why you are taking the medicine and possible side effects.

o Anytime you receive a medicine, shot or intravenous (IV) fluid, the nurse or other provider should ask for your name and birthdate. This

makes sure the right medication is given to the right patient.

Help Prevent Infections

o Ask everyone who enters your room to wash their hands or use hand

sanitizer. This helps to keep you safe from other people’s germs. o Make sure to get your flu or pneumonia vaccine.

Testing o Ask your doctor what the tests are for and what to expect.

o Find out how and when you will be told about your test results.

o Call the office if you do not receive your test results when you were expecting them.

Pain Management o Tell your doctor or nurse if you are uncomfortable or in pain. Most pain

can be controlled and will be addressed right away. It is OK to ask

again if you feel your pain has not been addressed.

Patients and their families are the most important partners on the healthcare

team. We want you to ask questions, give information, and help make decisions about your care.

.

Need to See a Doctor Today? Bronson has convenient healthcare options for you and your family.

When you aren't feeling well, the first step is to call your family doctor. If he or she is not available to see you promptly, you can use these Bronson services to receive

medical attention when your doctor may be unavailable or in cases of an emergency.

Bronson Clinics Bronson has appointments for current patients who need to be seen promptly and cannot be seen by their doctor.

Bronson After Hours Clinic

Bronson Internal Medicine Oshtemo 5629 Stadium Drive, Ste. B, Kalamazoo (269) 544-3275

Monday, Wednesday, Thursday, 5 - 8 p.m. Saturday, hours vary seasonally, 9 a.m. - 4 p.m.

Bronson LakeView Family Care Acute Care Clinic

451 Health Parkway, Paw Paw Call your provider for an appointment.

Open most weekdays, 8 a.m. - 6 p.m.

Nurse Triage Services Current patients of Bronson primary care practices can call their practice and be

redirected to a Bronson triage nurse. The triage nurse will help decide if the patient should stay

home and rest, schedule an appointment with a provider or seek emergency care.

Triage nurses are available after normal business hours and on the weekend.

Urgent Care Our urgent care staff provides timely, convenient, walk-in care for acute illnesses and injuries for all ages.

Bronson Battle Creek Outpatient Center -

Beckley Road 5352 Beckley Road, Battle Creek (269) 245-8000

Monday - Friday, 9 a.m. - 8 p.m. Weekends and holidays, 9 a.m. - 6 p.m.

Bronson FastCare Get help when you're sick—with little or no wait, for one low price of $69. FastCare has walk-in treatment for minor concerns such as

a sore throat, rashes or cold and flu symptoms.

5121 S. Westnedge Ave., Portage (269) 552-4212

Monday - Friday, 8:30 a.m. - 8:30 p.m. Saturday, 9 a.m. - 6 p.m.

Sunday, 10 a.m. - 5 p.m. Holidays, 10 a.m. - 2 p.m. (Closed Christmas Day)

24-Hour Emergency Services You can count on us to provide you with expert treatment for any serious injury or

illness.

Bronson Battle Creek Emergency Department 300 North Ave., Battle Creek

(269) 245-8000

Bronson LakeView Hospital Emergency Department 408 Hazen St., Paw Paw

(269) 657-3141

Bronson Trauma and Emergency Center 601 John St., Kalamazoo (269) 341-7654

Bronson’s Appointment Text Reminder Message

Directions to Bronson LakeView Family Care

date: welcome to bronson lakeview family care

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