NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
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.
Understanding your health record/information: Each time you
visit a healthcare facility or a member of your healthcare team
provides care or treatment, a record of your visit or treatment
is made. Typically, this record contains your name, address,
social security number, birth date, Medicare, Medicaid and insurance
information, past medical history, symptoms, examination information,
test results, diagnoses, treatment and a plan for future care
or treatment. This information, often referred to as your health
or medical record, serves as a:
• Basis for planning your care and treatment
• Means of communication between the many health professionals
who contribute to your care
• Legal document describing the care you received
• Means by which you or a third party payer can verify
that services billed were actually provided
• Tool in educating health professionals
• Source of data for medical research
• Source of information for public health officials who
oversee the delivery of healthcare in Michigan and the United
• Source of data for facility planning and marketing
• Tool with which we can assess and continually work to
improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information
is used helps you to ensure its accuracy, better understand
who, what, where and why others may access your health information,
and make more informed decisions when authorizing disclosure
Our facility is required to:
• Maintain the privacy of your health information
• Provide you with this notice as to our legal duties
and privacy practices with respect to information we collect,
maintain and disclose
• Abide by the terms of this notice
• Send you a revised Notice of Privacy Practices in advance
of any changes
Your Health Information Rights: Although your health record
is the physical property of this facility, the information in
your health record belongs to you. You have the following rights:
• You and your representative may request that we not
use or disclose your health information for a particular reason
related to treatment, payment, the facility’s general
healthcare operations and/or to a particular family member,
other relative or close personal friend. We ask that such requests
be made in writing on the Request To Restrict Use or Disclosure
of Protected Health Information Form. The form must be signed
and dated by you or your representative. Although we will consider
your request, please be aware that we are under no obligation
to accept it or to abide by it. We will notify you if we agree
or unable to agree to a requested restriction within two (2)
weeks of receipt.
• If you are dissatisfied with the manner in which, or
the location where, you are receiving communications from us
that are related to your health information, you may request
an alternative means or an alternative location. Such a request
must be made in writing and submitted to the Administrator.
We will attempt to accommodate all reasonable requests.
• You or your legal representative may request to inspect
and/or obtain copies of your medical record which will be provided
to you in the time frame established by law. If you request
copies, we will charge you a reasonable fee for the cost of
supplies for, and labor of, copying and postage if the copies
are to be mailed to your legal representative.
• If you believe that any health information in your record
is incorrect, or if you believe that important information is
missing, you may request that we correct the existing information
or add the missing information. The original entry cannot be
obscured. Such requests must be made in writing and must provide
a reason to support the amendment. We ask that you use the form
provided by our facility to make such requests.
• You or your legal representative may request that we
provide you with a written accounting of all disclosures made
by us during the time period for which you request (not to exceed
6 years). We ask that such requests be made in writing on the
form provided by our facility. Please note that an accounting
will not apply to any of the following types of disclosures:
disclosures made to you or your legal representative, any other
individual or entity designated below in this notice or disclosures
for national security purposes. You will not be charged for
your first accounting request in any 12-month period. However,
for any requests that you make thereafter, you will be charged
a reasonable, cost-based fee.
How and To Whom We Will Use and Disclose Your Health Information
1. To you.
2. Communication with family – a family member, other
relative, close personal friend or any other person you identify,
health information relevant to that person’s involvement
in your care or payment related to your care.
Notification – We may disclose information to notify or
assist in notifying a family member, personal representative
or another person responsible for your care of your location
and general condition. If we are unable to reach your family
member or personal representative, then we may leave a message
for them at the phone number that they have provided us, i.e.
on an answering machine.
Directory – Unless you notify us that you object, we may
use your name, location in the facility, general condition and
religious affiliation for directory purposes. This information
may be provided to members of the clergy and, except for religious
affiliation, to other people who ask for you by name. We may
also use your name on a nameplate next to, or on, your door
in order to identify your room, unless you notify us that you
Marketing – We may contact you to provide appointment
reminders or information about treatment alternatives or other
health-related benefits and services that may be of interest
to you. Periodically, your responsible party’s name and
address will be given to a firm to send a satisfaction survey.
Your name may also appear in our newsletter.
3. To our staff and ancillary services –
Treatment: We will use your health information for treatment.
For example, information obtained by a nurse, social worker,
physician, therapist, dentist, pharmacist, ophthalmologist,
psychologist or other member of your healthcare team will be
recorded in your record and used to determine the course of
treatment that should work best for you. Your physician will
document in your record his/her expectations of the members
of your healthcare team. Members of your healthcare team will
then record the actions they took and their observations. In
that way, the physician will know how you are responding to
treatment. We will also provide your physician or a subsequent
healthcare provider with copies of various reports that should
assist him/her in treating you once you are discharged from
our facility. Your name may appear on the outside of medical
chart binders and be in public view.
Healthcare Operations: We will use your health information for
regular health operations. For example, members of the medical
staff, the risk or quality improvement manager, members of the
quality improvement team or the main office specialist team,
etc. may use information in your health record to assess the
care and outcomes in your case and others like it. This information
will then be used in an effort to continually improve the quality
and effectiveness of the healthcare and service we provide.
4. For payment – For example, a bill from the main office
may be sent to you or a third party payer, including Medicare,
Medicaid, insurance companies, supply companies, etc. The information
on or accompanying the bill may include information that identifies
you, as well as your diagnosis, procedures and supplies used.
5. Other covered entities – For example, a hospital or
other nursing homes, assisted living or support services to
your home, ambulance company, etc. during your stay or upon
6. Business associates – There are some services provided
in our organization through contracts with business associates.
Examples include accountants, liability insurers, computer programmers
and technologists, consultants and attorneys. When these services
are contracted, we may disclose your health information to our
business associates so that they can perform the job we’ve
asked them to do. To protect your health information, however,
we require the business associates to appropriately safeguard
your information to prevent use or disclosure of the information
other than as permitted or required by the contract.
7. Funeral directors – We may disclose health information
to funeral directors and coroners to carry out their duties
consistent with applicable law.
8. Organ procurement organizations – Consistent with applicable
law, we may disclose health information to organ procurement
organizations or other entities engaged in the procurement,
banking or transplantation or organs for the purpose of facilitating
organ, eye and tissue donation and transplantation.
9. Food and Drug Administration (FDA) – We may disclose
to the FDA health information relative to adverse events with
respect to food, supplements, product and product defects or
post-marketing surveillance information to enable product recalls,
repairs or replacements.
10. Public health – As required by law, we may disclose
your health information to public health or legal authorities
charged with preventing or controlling disease, injury or disability.
We will also disclose your health information to surveyors responsible
for annual and/or complaint inspections. Ombudsmen may also
have access in the performance of their duties.
11. Law enforcement – We may disclose health information
for law enforcement purposes as required by law, for judicial/administrative
proceedings or in response to a valid subpoena.
Reports: Federal law makes provision for your health information
to be released to an appropriate health oversight agency, public
health authority or attorney, provided that a workforce member
or business associate believes in good faith that we have engaged
in unlawful conduct or have otherwise violated professional
or clinical standards and are potentially endangering one or
more residents, workers or the public.
12. Workers’ compensation – We may disclose health
information to the extent authorized by and to the extent necessary
to comply with laws relating to workers’ compensation,
OSHA or other similar programs established by law.
We will not use or disclose your health information without
your authorization except as described in 1 – 12 above.
Any other use or disclosure of your health information will
not be instituted without a written authorization from you or
your legal representative in advance. You may always revoke
the authorization to use or disclose health information except
to the extent that action has already been taken. Such a request
must be made in writing.
For More Information
or To Report a Problem
1. If you have questions and would like additional information,
you may contact our facility Administrator at _________________.
2. If you believe that your privacy rights have been violated,
you or your representative may file a complaint with us. This
complaint must be filed in writing within 180 days of occurrence
on the Resident Assistance Form provided by our facility.
3. You or your representative may also file a complaint with
the Secretary of the Federal Department of Health and Human
Service at Region V, Office for Civil Rights, US Department
of Health & Human Services, 233 N. Michigan Avenue, Suite
240, Chicago, IL 60601.
Phone 312-886-2359 or email firstname.lastname@example.org.
4. There will be no discrimination, intimidation or retaliation
to you or your representative for filing a complaint.
Effective date: April 2003