Notice of Privacy Practices

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SAINT JOSEPH MERCY HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES
06132012.6

Effective Date: April 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.

Saint Joseph Mercy Health System (referred to as SJMHS throughout the rest of this document) understands that your health information is highly personal, and we are committed to safeguarding your privacy. SJMHS is required by law to maintain the privacy of individually identifiable patient health information (this information is “protected health information” and is referred to as “PHI” throughout the rest
of this document). PHI includes identifiable information about your health care and payment for that health care. 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 SJMHS and its medical staff in our hospitals, outpatient departments, clinics, home care and hospice programs, system-owned physician practices, and pharmacies. This Notice also applies to the utilization review and quality assessment activities of Trinity Health and SJMHS as a member of Trinity Health.

I. Permitted Use or Disclosure

A. Treatment: SJMHS will use and disclose your PHI in the provision and coordination of health care to carry out treatment functions.

• SJMHS will disclose all or any portion of your patient medical record information to your attending physician, consulting physician(s), nurses, technicians, medical students and other health care providers who have a legitimate need for such information in your care and continued treatment.
• SJMHS is a Catholic sponsored health care provider. Spiritual care providers, or chaplains, are members of our care staff and will be a part of SJMHS’s team of care providers who use your medical information to provide health care services to you when you are in SJMHS’s facilities.
• Different departments or areas of SJMHS will share medical information about you in order to coordinate specific services, such as lab work, x-rays and prescriptions.
• SJMHS will disclose your medical information to people or entities outside SJMHS who will be involved in your medical care after you leave SJMHS, such as family members, friends, community clergy and others who will provide services that are part of your care.
• SJMHS 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.
• SJMHS will use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.
• SJMHS will use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at SJMHS.
• If you are an inmate of a correctional institution or under the custody of a law enforcement officer, SJMHS will disclose your PHI to the correctional institution or law enforcement official.

B. Payment: SJMHS 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.
• SJMHS will disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.
• SJMHS will disclose PHI to other health care providers who are engaged in obtaining payment for care.

C. Health Care Operations: SJMHS will use and disclose your PHI during routine health care operations including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of SJMHS, and for educational purposes.

• For instance, SJMHS 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. SJMHS will need to share your PHI for customer service activities. SJMHS also contributes to databases compiled for benchmarking and quality improvement.

D. Other Uses and Disclosures: As part of treatment, payment and health care operations, we may also use your PHI for the following purposes:

• Fundraising Activities: SJMHS maintains a database of information to contact individuals for fund-raising initiatives designed to expand and improve the services and programs we provide to the community. The information we use includes name, address, telephone number, age, gender and dates of service. SJMHS may disclose limited PHI from this database to a company contracted to conduct fundraising for SJMHS. This company will use your PHI only for the purposes of fundraising for SJMHS. You may be included in this database. If you do not wish to be contacted for fund-raising efforts, please notify us in writing at Development Department, P.O. Box 995, Ann Arbor, MI 48106-0995.
• Health Care Research: SJMHS may disclose your PHI without your Authorization to health care researchers who request it for certain types of health care research projects (typical projects involve mailing surveys or collecting data from medical records); 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: SJMHS 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. SJMHS will also send you information based on your own health concerns. SJMHS 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.
  
  More Stringent State and Federal Laws:
  The information in this notice complies with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) regulations. In some cases, other State or Federal Laws may be more stringent than the HIPAA regulations. SJMHS will continue to abide by these more stringent state and federal laws. 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. Examples of state laws include: 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. Federal laws that are more stringent 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

II. Permitted Use or Disclosure with an Opportunity for You to Agree or Object

A. Family/Friends: SJMHS will disclose PHI about you to a friend or family member who is involved in your medical care. SJMHS will also give information to family members, friends or others who help you pay for your care. In addition, SJMHS 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. Facility Directory: SJMHS will include certain limited information about you in the Facility Directory. The Facility Directory is a list of people who are currently patients in the hospital. This information will include your name, location in SJMHS, your general condition (“good,” “fair,” “serious,” or “critical”) and your religious and/or congregational affiliation. This is so your family, friends, or clergy can visit you in the hospital and know how you are doing. The directory information, except for your religious and/or congregational affiliation, will be disclosed to people who ask for you by name. The directory information including your religious and/or congregational affiliation will be given to a community clergy member, such as a pastor, priest, rabbi, or imam, who asks for you by name, by religious affiliation or by congregational affiliation. If you request us to do so, we will inform your clergy directly of your location in SJMHS. You have the right to request that your name not be included in the Facility Directory. If you request to opt out of the Facility Directory, we cannot inform visitors or callers of your presence, location, or general condition. Visitors or callers will be told that we have no information on a person by that name.

C. Promotional Communications: SJMHS 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. SJMHS does maintain a database of individuals for promotional communications. This database includes individuals to whom SJMHS may have sent health improvement or health promotion materials and news about SJMHS. SJMHS sends information to the individuals in this database about the programs and services of SJMHS. You may be included in this database. If you do not wish to be contacted for promotional communications, please notify us in writing at Marketing Department, P.O. Box 995, Ann Arbor, MI 48106-0995.

D. Media Condition Reports: SJMHS may release information for an update to the media if the media requests information about you using your full name and after we have given you an opportunity to agree or object. The following information may then be disclosed: your condition described in general terms that do not communicate specific medical information, such as “good,” “fair,” “serious,” or “critical.”

III. Use or Disclosure Requiring Your Authorization

A. Marketing: SJMHS is permitted to use your PHI for the purpose of sending you information about SJMHS’s products or services. However, we must obtain your authorization to use your PHI if SJMHS is receiving payment in exchange for the marketing communication. SJMHS does not provide your PHI to any other person or company for marketing of their products or services.

B. Research: For many types of research, SJMHS will be required to obtain your authorization before allowing the researchers to use or disclose your PHI. A special approval process is required for these types of research projects before your PHI is shared.

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.

D. General Authorization for Use or Disclosure of Health Information forms are available by contacting the Health Information Management Department at the hospital associated with your care (734-712-3526 for SJMHS Ann Arbor, Saline and Livingston; 734-655-2416 for St. Mary Mercy Hospital; 734-475-3982 for Chelsea Community Hospital); or by printing the form here.

IV. Use or Disclosure Permitted by Public Policy or Law without your Authorization

A. Law Enforcement Purposes: SJMHS 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 criminal conduct.

B. Required by Law: SJMHS will disclose PHI about you when required by federal, state or local law to make reports or other disclosures. SJMHS also will make disclosures for judicial and administrative proceedings such as lawsuits or other disputes in response to a court order or subpoena. SJMHS will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violence. SJMHS 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. SJMHS will make certain disclosures that are required in order to comply with workers’ compensation or similar programs.

C. Coroners, Medical Examiners, Funeral Directors: SJMHS will disclose your PHI to a coroner or medical examiner. For example, this will be necessary to identify a deceased person or to determine a cause of death. SJMHS will also disclose your medical information to funeral directors as necessary to carry out their duties.

D. Organ Procurement: SJMHS will disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes.

E. Health or Safety: SJMHS will use and disclose PHI to avert a serious threat to health and safety of a person or the public. SJMHS will use and disclose PHI to Public Health Agencies for immunizations, communicable diseases, etc. SJMHS 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

SJMHS must maintain all records concerning your hospitalization and treatment by SJMHS. 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 copy your PHI as long as we maintain it except for: psychotherapy notes, information that will be used in a civil, criminal or administrative action or proceeding, and where prohibited or protected by law. You also have the right to request your PHI in electronic format if the service where you received your care is using an electronic health record. SJMHS will deny your request for access to your PHI without giving you an opportunity to review that decision if:

• You don’t have the right to inspect the information; or it is otherwise prohibited or protected by law;
• You are an inmate at a correctional institution and obtaining a copy of the information would risk the health, safety, security, custody or rehabilitation of you or other inmates;
• The disclosure of the information would threaten the safety of any officer, employee or other person at the correctional institution or who is responsible for transporting you;
• You are involved in a clinical research project and SJMHS created or obtained the PHI during that research. Your access to the information will be temporarily suspended for as long as the research is in progress;
• SJMHS obtained the information that you seek access to from someone other than the health care provider under a promise of confidentiality and your access request is likely to reveal the source of the information; or
• Under other limited circumstances. In these instances, however, SJMHS will allow the review of its decision by a health care professional that SJMHS has chosen. This person will not have been involved in the original decision to deny your request.

You must make your requests to access and copy your PHI in writing to SJMHS. Request to Access Health Information forms are available by contacting the Health Information Management Department or by printing the form from the hospital web site at http://www.sjmercyhealth.org. SJMHS will respond to your request within 30 days of its receipt. If SJMHS cannot, SJMHS will notify you in writing to explain the delay and the date by which we will act on your request. In any event, SJMHS will act on your request within 60 days of its receipt.

You may be required to pay a reasonable copying fee for your request. You will be provided with information regarding fees when you make your request.

B. Right to Amend: You have the right to amend your PHI for as long as SJMHS maintains it. However, SJMHS will deny your request for amendment if:

• SJMHS did not create the information;
• The information is not part of the designated record set;
• The information would not be available for your inspection (due to its condition or nature); or
• SJMHS has found the information to be accurate and complete.

If SJMHS denies your request to amend your PHI, SJMHS will notify you in writing with the reason for the denial. SJMHS will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that SJMHS include your request for amendment and the denial any time that SJMHS discloses the information that you wanted changed. SJMHS 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 SJMHS, including your reason to support the requested amendment. Request to Amend or Correct Health Information forms are available by contacting the Health Information Management Department or by printing the form from the hospital web site at http://www.stjoeshealth.org. SJMHS will respond to your request within 60 days of its receipt. If SJMHS cannot, SJMHS will notify you in writing to explain the delay and the date by which SJMHS will act on your request. In any event, SJMHS 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 SJMHS made, except for the following disclosures:

• To carry out treatment, payment or health care operations;
• In response to an authorization signed by you
• To you;
• To persons involved in your care;
• For national security or intelligence purposes;
• To correctional institutions or law enforcement officials; or
• That occurred prior to April 14, 2003.

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 SJMHS. Forms are available by contacting the Health Information Management Department or by printing the form from the hospital web site at http://www.sjmercyhealth.org. You must include the time period of the accounting, which may not be longer than 6 years. SJMHS will respond to your request within 60 days from its receipt. If SJMHS cannot, SJMHS will notify you in writing to explain the delay and the date by which SJMHS will act on your request. In any event, SJMHS will act on your request within 90 days of its receipt.

In any given 12-month period, SJMHS will provide you with an accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting within that time period will be subject to a reasonable fee for preparing the accounting. Contact Health Information Management for information on current fees.

D. Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or health care operations functions. SJMHS will consider your request, but is not required to agree to it. For example, you may ask that your name not be used in the waiting room or that information about your expected discharge date not be shared with your family. A request for a restriction must be made in writing. Request for Restriction on Uses and Disclosures of Health Information forms are available by contacting the Health Information Management Department or by printing the form from the hospital web site at http://www.sjmercyhealth.org.

You have a right to limit release of PHI to family, friends, or in the facility directory (see Section II – Opportunity for You to Agree or Object). You also have the right to request a restriction on disclosure of your PHI to a health plan (for purpose of payment or health plan operations) in cases where you’ve paid out of pocket, in full, for the items received or services rendered.

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 SJMHS only contact you at work or by mail. A request for a confidential communication must be made in writing. Request for Confidential Communications forms are available by contacting the Health Information Management Department or by printing the form from the hospital web site at http://www.sjmercyhealth.org.

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. A copy may also be printed from the SJMHS web site at http://www.sjmercyhealth.org.

VI. Breach of Unsecured PHI

If a breach of unsecured PHI occurs which poses a significant risk of harm to you, SJMHS will notify you that a breach in the privacy or security of your PHI has occurred.

VII. Complaints

If you believe your privacy rights have been violated, you may file a complaint with SJMHS or with the Secretary of the Department of
Health and Human Services. Complaints may be submitted in writing or by calling the Patient Relations Department at 734-712-2700 or the Privacy Officer at 734-712-4542. For St. Mary Mercy Hospital related complaints, contact the Privacy Officer at 734-655-1409. Privacy Complaint forms for written complaints are available by calling the above numbers, or by printing the form from the hospital’s web site at http://www.sjmercyhealth.org. SJMHS will acknowledge receipt of your complaint, either verbally or in writing, within a reasonable period of time. SJMHS assures you that there will be no retaliation for filing a complaint.

VIII. Sharing and joint use of your Health Information

In the course of providing care to you and in furtherance of the SJMHS’s mission to improve the health of the community, SJMHS will share your PHI with other organizations as described below who have agreed to abide by the terms described below:

A. Medical Staff: The medical staff and SJMHS participate together in an organized health care arrangement to deliver health care to you at SJMHS. Both SJMHS and its medical staff have agreed to abide by the terms of this Notice with respect to PHI created or received as part of delivery of health care services to you in SJMHS. Physicians and allied health care providers are members of SJMHS’s medical staff and will have access to and use of your PHI for treatment, payment and health care operations purposes related to your care within SJMHS. SJMHS will disclose your PHI to the medical staff for treatment, payment, and health care operations.

B. Business Associates: SJMHS will use and disclose your PHI to business associates contracted to perform business functions on its behalf including Trinity Health, its parent company who performs certain business functions for SJMHS. Whenever an arrangement between SJMHS and another company involves the use or disclosure of your PHI, that business associate will be required to keep your information confidential.

C. Membership in Trinity Health: SJMHS, a member of Trinity Health, and Trinity Health 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 Trinity Health and its members. Members of Trinity Health will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or healthcare operations. SJMHS and other hospitals, nursing homes, and health care providers in Trinity Health share your PHI for utilization review and quality assessment activities of Trinity Health, the parent company, and its members. Members of Trinity Health also use your PHI for your treatment, payment to SJMHS and/or for the health care operations permitted by HIPAA with respect to our mutual patients.

D. Affiliations: SJMHS is affiliated with the following health care organizations in which SJMHS is an owner or co-owner:
St. Joseph Mercy Hospital, St. Joseph Mercy Saline Hospital, St. Joseph Mercy Livingston Hospital, St. Mary Mercy Hospital, Chelsea Community Hospital, St. Joseph Mercy Home Care, St. Joseph Mercy Hospice, St. Joseph Mercy Livingston Home Care, St. Joseph Mercy Livingston Hospice, St. Joseph Mercy Pharmacy, St. Joseph Mercy Medical Group Physician Offices, Michigan Heart, St. Joseph Mercy Woodland Health Center, St. Joseph Mercy Canton Health Center, St. Joseph Mercy Maple Health Building, St. Joseph Mercy Arbor Health Center, St. Joseph Mercy Reichert Health Center, Chelsea Community Hospital Laboratory, ChelseaCare Home Health and Pharmacy, Chelsea Community Hospital Physician Practices, Warde Medical Laboratory/ Michigan Co-Tenancy Laboratory, Avant Imaging.

SJMHS will share your PHI with these organizations for purposes of your treatment, payment and health care operations by these organizations.

IX. Additional Information

To obtain further information regarding the issues covered by this Notice of Privacy Practices:
For Ann Arbor, Chelsea, Livingston and Saline, please contact:
Privacy Officer, 5301 East Huron River Drive, PO Box 995,
Ann Arbor, MI 48106-0995. Telephone: 734-712-4542.

For St. Mary Mercy, please contact:
Privacy Official, 36475 Five Mile Road, Livonia, MI 48154.
Telephone: 734-655-1409.

IX. Changes to this Notice

SJMHS will abide by the terms of the Notice currently in effect. SJMHS reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. SJMHS will provide you with the revised Notice at your first visit following the revision of the Notice.