Notice of Health Information Privacy Practices

Effective March 2003

This Notice acknowledges that Chelsea Community Hospital and the members of its Medical Staff jointly perform various treatment and operations activities. In carrying out their responsibilities, the Medical Staff have access to protected health information (PHI) for purposes of treatment, payment and the health care operations of the Hospital. The members of the Medical Staff agree to abide by this Notice when providing care and other services that take place at Chelsea Community Hospital. If you have any questions about this notice, please speak with your treatment team or contact Ruth Shantz, Privacy Officer for Chelsea Community Hospital at (734) 475-3911.

WHO WILL FOLLOW THIS NOTICE: This notice describes Chelsea Community Hospital's practices and that of: - Any health care professional authorized to enter information into your medical record. - All departments and units of the Hospital. - Any member of a volunteer group we allow to help you while you are in the Hospital. - All employees, staff and other Hospital personnel.

OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive at the Hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Hospital, whether made by Hospital personnel or your attending physician. Your pysician may have different policies or notices regarding the physician's use and disclosure of your information created in the physician's office. This notice will tell you about the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to:

• make sure that health information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to health information about you;
• and follow the terms of the notice that is currently in effect.

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HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

1. For Treatment. We use health information about you to provide you with medical treatment or services. We disclose health information about you to physicians, nurses, therapists, technicians, health care students, or other Hospital personnel who are involved in taking care of you at the Hospital. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the physician may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the Hospital also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside the Hospital who may be involved in your medical care after you leave the Hospital, such as health care professionals, health care facilities, home health agencies, family members, or others we use to provide services that are part of your follow-up or ongoing care. Information about you may also be disclosed to physicians who provide on-call coverage for our physician practices.

2. For Payment. We use and disclose health information about you so that the treatment and services you receive here may be billed to and payment may be collected from an insurance company (health plan), a third party, or from you. For example, we may need to give your health plan information about surgery you received at the Hospital so your health plan will pay us or reimburse you for the surgery. We may also give information to a physician's billing company for purposes of billing the professional fee (e.g., anesthesiology, radiology, emergency care or pathology). If you arrive by ambulance, we will share limited information with the ambulance company for purposes of billing their fee. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine if your plan will cover the treatment.

3. For Health Care Operations. We may use and disclose health information about you for Hospital operations. These uses and disclosures are necessary to run the Hospital and make sure that all of our patients receive quality care. For example, we may disclose information to physicians, nurses, technicians, students, and other Hospital personnel for review and learning purposes. We may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many Hospital patients to decide what additional services the Hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also combine the health information we have with health information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are. Sometimes insurance companies and other third parties conduct audits to confirm that appropriate claims and payments were submitted. We may use and disclose your health information as a part of these audits. We may also disclose limited information to the company that conducts patient satisfaction surveys for the Hospital.

4. Appointment Reminders. We may use and disclose limited information to contact you as a reminder that you have an appointment for treatment or medical care at the Hospital or outpatient service.

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5. Health-Related Products and Services. We may use health information to tell you, now or in the future, about the Hospital's health-related products or services that may be of interest to you.

6. Fundraising Activities. We may use limited information about you to contact you in an effort to raise money for the Hospital. If you do not want the Hospital to contact you for fundraising efforts, you must notify Public Relations, 775 S. Main, Chelsea, MI 48118 in writing.

7. Final Patient Census. We may include certain limited information about you in the Patient Census while you are an inpatient at the Hospital. This information may include your name, location in the Hospital, and any religious affiliation. This information, except for your religious affiliation, may also be released to people who ask for you by name. This is so your family and friends can visit you in the Hospital. Your religious affiliation may be given to a member of the clergy of your same religion, unless you specifically tell us not to release this information.

8. Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also give your room number to your family or friends who are not involved in your care if they have asked for you by name. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

9. Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information. The research needs will be balanced with patients' need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process. However, we may disclose health information about you to people preparing to conduct a research project in order to help them look for patients with specific medical needs. In this circumstance, the health information they review does not leave the Hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are.

10. As Required By Law. We will disclose health information about you when required to do so by federal, state or local law.

11. To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent harm.

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SPECIAL SITUATIONS

12. Organ and Tissue Donation. In the event of death, and as required by law, we will release health information necessary to facilitate organ and/or tissue donation and transplantation.

13. Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

14. Workers' Compensation. We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

15. Public Health Risks. We may disclose health information about you for public health records and follow-up. These disclosures occur in order to: - prevent or control disease, injury or disability; - report births and deaths; - report child abuse or neglect; - report reactions to medications or problems with products; - notify people of recalls of products they may be using; - notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; - notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

16. Health Oversight Activities. We may disclose health information to an agency, authorized by law, to oversee healthcare activities. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

17. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to obtain your written authorization to release the information or to obtain an order protecting the information requested.

18. Law Enforcement. We may release health information if asked to do so by a law enforcement official: - If an order, subpoena, warrant, or summons is issued by a court; - About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; - About a death we believe may be the result of criminal conduct; - About criminal conduct at the Hospital; and - In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

19. Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients of the Hospital to funeral directors as necessary to carry out their duties.

20. National Security and Intelligence Activities. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

21. Inmates. If you are an inmate of a correctional institution, we may release medical information about you to the correctional institution. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

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YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy your health information, you must submit your request in writing. If you request a copy of the information, we will generally charge a fee for the costs of copying, mailing or other supplies associated with your request. If you have been discharged, your request should be directed to the Medical Records Department. If you are involved in continuing care, your request should be directed to a member of your treatment team. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. If you make this request, Hospital Administration will review your request and the denial.

Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the health information is kept by or for the Hospital. To request an amendment, your request must be made in writing and submitted to the Medical Records Department. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; Is not part of the medical information kept by or for the Hospital; Is not part of the information which you would be permitted to inspect and copy; or Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures" (a list of the disclosures we made of health information about you) except that the Hospital does not have to account for the disclosures described in parts 1- 9, 12, 16 and 21 above. To request this list or accounting of disclosures, you must submit your request in writing to the Medical Records Department. Your request must state a time period that may not be longer than six years and may not include dates before February 26, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or unless information was already provided prior to your request. To request restrictions, you must make your request in writing to the Medical Records Department.

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In your request, you must tell us:

(1) what information you want to limit;

(2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to a member of your treatment team. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You may obtain a copy of this notice at our website, www.cch.org. You may also obtain a paper copy of this notice by contacting the Hospital's Admitting Office.

CHANGES TO THIS NOTICE. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the Hospital. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the Hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the Hospital, contact Ruth Shantz, Associate Administrator and Privacy Officer at (734) 475-3911. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION. Other uses and disclosures of health information not covered by this notice or the laws that apply will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.