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We are currently accepting new patients. GRAYLING PRUDENVILLE
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MERCY SURGICAL SERVICES Effective Date: 4/14/2003 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 physician's practice is part of Mercy Surgical Services and is referred to herein as "MSS". MSS is a member of
Mercy Hospital Grayling and an affiliate of Munson Healthcare. We are
required by law to maintain the privacy of individually identifiable
patient health information (this information is "protected health
information" and is referred to herein as "PHI"). We
are also required to provide patients with a Notice of Privacy Practices
regarding PHI. We are required to post this Notice in a prominent place
within our facility. We will only use or disclose your PHI as permitted
or required by applicable state law. This Notice applies to your PHI
in our possession including the medical records generated by us. This Notice applies to the delivery of health care
by Mercy Family Care (MSS). This Notice also applies to the utilization
review and quality assessment activities of Mercy Hospital Grayling,
Munson Healthcare and MSS as a member of Mercy Hospital Grayling and
an affiliate of Munson Healthcare. I. Permitted Use or Disclosure A. Treatment: MSS will use and disclose your
PHI in the provision and coordination of health care to carry out treatment
functions. Different departments will share medical information
about you in order to coordinate specific services, such as lab work,
x-rays and prescriptions. MSS also will disclose your medical information
to people or entities outside MSS who will be involved in your medical
care after you leave MSS, such as other care providers who will provide
services that are part of your care. MSS will share certain information such as your
name, address, employment, insurance carrier, emergency contact information
and appointment scheduling information in an effort to coordinate your
treatment with us and with other health care providers. MSS will use and disclose your PHI to inform you
of, or recommend possible treatment options or alternatives that will
be of interest to you. MSS will use and disclose PHI to contact you as
a reminder that you have an appointment for medical care at MSS. If you are an inmate of a correctional institution
or under the custody of a law enforcement officer, MSS will disclose
your PHI to the correctional institution or law enforcement official. B. Payment: MSS will disclose PHI about you
for the purposes of determining coverage, eligibility, funding, billing,
claims management, medical data processing, stop loss/reinsurance and
reimbursement. The medical information will be disclosed to an
insurance company, third party payer, third party administrator, health
plan or other health care provider (or their duly authorized representatives)
involved in the payment of your medical bill and will include copies
or excerpts of your medical records which are necessary for payment
of your account. It will also include sharing the necessary information
to obtain pre-approval for payment for treatment from your health plan.
MSS will disclose PHI to collection agencies and
other subcontractors engaged in obtaining payment for care. C. Health Care Operations: MSS will use and
disclose your PHI during routine health care operations including quality
review, utilization review, medical review, internal auditing, accreditation,
certification, licensing or credentialing activities of MSS, and for
educational purposes. For instance, MSS will need to share your demographic
information, diagnosis, treatment plan and health status for population
based activities relating to improving health or reducing health care
costs, protocol development, case management and care coordination,
and contacting health care providers and patients with information about
treatment alternatives, in order for us to operate our business in an
efficient, safe and legal manner. MSS may also use and disclose your PHI to support
the sale, transfer, or other corporate restructuring of Mercy Hospital
Grayling's assets. D. Other Uses and Disclosures: As part of
treatment, payment and health care operations, we may also use your
PHI for the following purposes: Medical Research: MSS may disclose your PHI
without your Authorization to medical researchers who request it for
approved medical research projects; however, with very limited exceptions
such disclosures must be cleared through a special approval process
before any PHI is disclosed to the researchers. Researchers will be
required to safeguard the PHI they receive. Information and Health Promotion Activities:
MSS will use and disclose some of your PHI for certain health promotion
activities. For example, your name and address will be used to send
you newsletters or general communications. MSS will also send you information
based on your own health concerns. MSS may send you this information
if it has determined that a product or service may help you. The communication
will explain how the product or service relates to your well being and
can improve your health. E. More Stringent State and Federal Laws:
The State law of Michigan is more stringent than HIPAA in several areas.
State law is more stringent when the individual is entitled to greater
access to records than under HIPAA and when under state law the records
are more protected from disclosure than under HIPAA. Certain federal
laws also are more stringent than HIPAA. The MSS will continue to abide
by these more stringent state and federal laws. The federal laws include
applicable internet privacy laws, such as the Children's Online Privacy
Protection Act and the federal laws and regulations governing the confidentiality
of health information regarding substance abuse treatment. In Michigan patients have more rights of access
to behavioral health information under Michigan law than under HIPAA
and the state law defines a minimum necessary standard for release of
mental health information. Disclosure is permitted with consent and
for treatment without consent but only in an emergency. Minors in Michigan
have more rights to confidentiality and protection of certain information
(reproductive health, behavioral health and substance abuse) than under
HIPAA. State law requires facilities to adopt policies regarding release
of information outside the facility. If the facility policy requires
consent for release, then consent will be required. State law genetic
and HIV testing and disclosure consents remain in place. II. Permitted Use or Disclosure with an Opportunity
for You to Agree or Object A. Family/Friends: With your permission,
MSS will disclose PHI about you to a friend or family member who is
involved in your medical care. MSS will also give information to someone
who helps you pay for your care. In addition, MSS will disclose PHI
about you to an agency assisting in a disaster relief effort so that
your family can be notified about your condition, status and location.
You have a right to request that your PHI not be shared with some or
all of your family or friends. B. Promotional Communications: MSS does not
share or sell your PHI to companies that market health care products
or services directly to consumers for use by those companies to contact
you, such as drug companies. The MSS does maintain a database of individuals
for promotional communications, disease management, and health promotion
purposes. MSS sends information to the individuals in this database
about the programs and services of MSS. If you wish to be deleted from
this database, you may notify the Privacy Official. III. Use or Disclosure Requiring Your Authorization A. Marketing: MSS is not permitted to provide
your PHI to any other person or company for marketing to you of any
products or services other than the MSS products or services without
a signed authorization from you. B. Research: MSS will use or disclose your
PHI as part of research that includes providing you with treatment.
For example, if you are part of a research study that includes treatment,
the MSS may require that you sign an authorization to allow the researchers
to use or disclose your PHI for this research. C. Other Uses: Any uses or disclosures that
are not for treatment, payment or operations and that are not permitted
or required for public policy purposes or by law will be made only with
your written authorization. Written authorizations will let you know
why we are using your PHI. You have the right to revoke an authorization
at any time, except to the extent that MSS has taken action in reliance
on the authorization. IV. Use or Disclosure Permitted by Public Policy or Law without your Authorization A. Law Enforcement Purposes: MSS will disclose
your PHI for law enforcement purposes as required by law, such as responding
to a court order or subpoena, identifying a criminal suspect or a missing
person, or providing information about a crime victim or possible criminal
conduct as part of a criminal investigation. Required by Law: MSS will disclose PHI about
you when required by federal, state or local law to make reports or
other disclosures. MSS also will make disclosures for judicial and administrative
proceedings such as lawsuits or other disputes in response to a court
order or subpoena. MSS will disclose your medical information to government
agencies concerning victims of abuse, neglect or domestic violence.
MSS will report drug diversion and information related to fraudulent
prescription activity to law enforcement and regulatory agencies. Specialized
government functions will warrant the use and disclosure of PHI. These
government functions will include military and veteran's activities,
national security and intelligence activities, and protective services
for the President and others. MSS will make certain disclosures that
are required in order to comply with workers' compensation or similar
programs. B. Health or Safety: Following the requirements
of the Michigan Department of Commerce, MSS will use and disclose PHI
to avert a serious threat to health and safety of a person or the public.
MSS will use and disclose PHI to Public Health Agencies for immunizations,
communicable diseases, etc. MSS will use and disclose PHI for activities
related to the quality, safety or effectiveness of FDA-regulated products
or activities, including collecting and reporting adverse events, tracking
and facilitating product recalls, etc. and post marketing surveillance.
Any patient receiving a medical device subject to FDA tracking requirements
may refuse to disclose, or refuse permission to disclose, their name,
address, telephone number and social security number, or other identifying
information for the purpose of tracking. V. Your Health Information Rights Although we at MSS must maintain all records concerning
your treatment by the MSS, you have the following rights concerning
your PHI: A. Right to Inspect and Copy: You have the
right to access your PHI and to inspect and have a copy made of your
PHI as long as we maintain it except for: psychotherapy notes, information
that may be used in anticipation of, or that will be used in a civil,
criminal or administrative action or proceeding, and where prohibited
or protected by law. MSS will deny your request for access to your PHI
without giving you an opportunity to review that decision if:
You agree to pay a reasonable copying charge. You
must make your requests to access and copy your PHI in writing to MSS.
MSS will respond to your request within 30 days of its receipt. If MSS
cannot, MSS will notify you in writing to explain the delay and the
date by which we will act on your request. In any event, MSS will act
on your request within 60 days of its receipt. B. Right to Amend: You have the right to
amend your PHI for as long as MSS maintains it. However, MSS will deny
your request for amendment if:
If MSS denies your request for changes in your PHI,
MSS will notify you in writing with the reason for the denial. MSS will
also inform you of your right to submit a written statement disagreeing
with the denial. You may ask that MSS include your request for amendment
and the denial any time that MSS discloses the information that you
wanted changed. MSS may prepare a rebuttal to your statement of disagreement
and will provide you with a copy of that rebuttal. You must make your request for amendment of your
PHI in writing to MSS, including your reason to support the requested
amendment. MSS will respond to your request within 60 days of its receipt.
If MSS cannot, MSS will notify you in writing to explain the delay and
the date by which MSS will act on your request. In any event, MSS will
act on your request within 90 days of its receipt. C. Right to an Accounting: You have a right
to receive an accounting of the disclosures of your PHI that MSS made,
except for the following disclosures:
For each disclosure, you will receive: the date
of the disclosure, the name of the receiving organization and address
if known, a brief description of the PHI disclosed and a brief statement
of the purpose of the disclosure or a copy of the written request for
the information, if there was one. You must make your request for an accounting of
disclosures of your PHI in writing to MSS. You must include the time
period of the accounting, which may not be longer than 6 years. MSS
will respond to your request within 60 days from its receipt. If MSS
cannot, MSS will notify you in writing to explain the delay and the
date by which MSS will act on your request. In any event, MSS will act
on your request within 90 days of its receipt. D. Right to Request Restrictions: You have
the right to request restrictions on certain uses and disclosures of
your PHI:
For example, you may ask that your name not be used
in the waiting room or that information about your condition not be
shared with your family. MSS will consider your request but is not required
to agree to the requested restrictions. E. Right to Confidential Communications:
You have the right to receive confidential communications of your PHI
by alternative means or at alternative locations. For example, you may
request that MSS only contact you at work or by mail. F. Right to Receive a Copy of this Notice:
You have the right to receive a paper copy of this Notice of Privacy
Practices, upon request. VI. Complaints If you believe your privacy rights have been violated,
you may file a complaint with MSS or with the Secretary of the Department
of Health and Human Services. To file a complaint with MSS, please contact
MSS's Privacy Official, at: Mercy Family Care — Grayling Mercy Family Care — Roscommon Mercy Family Care — Prudenville All complaints must be submitted in writing directly
to MSS's Privacy Official. MSS assures you that there will be no retaliation
for filing a complaint. VII. Sharing and joint use of your Health Information
In the course of providing care to you and in furtherance
of our mission to improve the health of the community, MSS will share
your PHI with other organizations as described below who have agreed
to abide by the terms described below: A. Business Associates: MSS will use and
disclose your PHI to business associates contracted to perform business
functions on its behalf including Mercy Hospital Grayling (its parent)
and Munson Healthcare (its affiliate), who perform certain business
functions for MSS. Whenever an arrangement between MSS and another company
involves the use or disclosure of your PHI, that business associate
will be required to keep your information confidential. B. Membership in Mercy Hospital Grayling and
Munson Healthcare: MSS and other members of Mercy Hospital Grayling
and Munson Healthcare participate together in an organized health care
arrangement for utilization review and quality assessment activities.
We have agreed to abide by the terms of this Notice with respect to
PHI created or received as part of utilization review and quality assessment
activities of Mercy Hospital Grayling, Munson Healthcare and their members.
Members of Mercy Hospital Grayling and Munson Healthcare will abide
by the terms of their own Notice of Privacy Practices in using your
PHI for treatment, payment or healthcare operations. As a part of Mercy
Hospital Grayling/Munson Healthcare, MSS and the various hospitals,
nursing homes, and health care providers in Mercy Hospital Grayling
and Munson Healthcare share your PHI for utilization review and quality
assessment activities of Mercy Hospital Grayling and Munson Healthcare.
Members of Mercy Hospital Grayling and Munson Healthcare may also use
your PHI for your treatment, payment to MSS and/or for the health care
operations permitted by HIPAA with respect to our mutual patients. VIII. Additional Information For further information regarding the issues covered
by this Notice of Privacy Practice, please contact MSS's Privacy Official,
at GRAYLING: IX. Changes to this Notice MSS will abide by the terms of the Notice currently in effect. MSS reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. Any revised Notice will contain the new effective date. Upon your request, we will provide you with the revised Notice of Privacy Practices by calling the offices and requesting a revised copy be sent by mail or by asking for one at your next visit. |
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