Marian E. Burch Adult Day Care Center
Battle Creek, MI 49014
Phone: (269) 962-1750
Effective Date: April 14, 2003
Date(s) of revision: _____________
Please contact Rhonda Staib, Privacy Officer at (269) 962-5458 ext.113 if you have any questions regarding this notice.
Each time you visit a health care 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 symptoms, examination, test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical records, 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 are a third party payer can verify that services
billed were actually provided
· Tools in educating health professionals
· Source of data for medical research
· Source of information for public health officials who oversee the
delivery of health care in the United States and Michigan
· Source of data for facility planning and marketing
· Tool with which we can assess and continually work to improve
the care we render and 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, when and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
We are committed to preserving the privacy and confidentiality of your health information created and/or maintained at our Center. Certain state and federal laws and regulations require us to implement policies and procedures to safeguard the privacy or your health information.
Our Center is required to:
§ Maintain the privacy of your health information
§ Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
§ Abide by the terms of notice
§ Notify you if we are unable to agree to a requested restriction
§ Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
This notice will provide you with information regarding our privacy practices and applies to all of your health information created and/or maintained at our Center, including any information that we receive from other health care providers or centers. The notice described the ways in which we may use or disclose your health information and also describes your rights and our obligations regarding any such uses or disclosures. We will abide by the terms of this notice, including any future revisions that we may make to the notice as required by law.
We reserve the right to change this notice and 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 promptly mail you or your designated representative a revised notice. The first page of the notice contains the effective date and any dates of revision.
The following describes each of the different ways that we may use or disclose your health information. Where appropriate, we have included examples of the different type of uses or disclosures. While not every use or disclosure is listed, we have included all of the ways in which we may make such used or disclosures.
We will not use or disclose your health information without your authorization, except as described in this note.
1. Treatment. We may use your health information to provide you with health care treatment and services. We may disclose your health information to doctors, nurses, nursing assistants, medication aides, technicians, medical and nursing students, rehabilitation therapy specialists, or other personnel who are involved in your health care. For example, your physician may order physical therapy services to improve your strength and walking abilities. Our nursing staff will need to talk with the physical therapist so that we can coordinate information to people outside of our Center who may be involved in your health care, such as family members, social services, or home health agencies.
a. Treatment alternatives, Health-related benefits and services. We may use or disclose your health information for purposes of contracting you to inform you of treatment alternatives or health-related benefits and services that may be of interest to you.
b. Appointment reminders. We may use of disclose your health information for purposes of contracting you to remind you of a health care appointment.
2. Payment. We may use or disclose your health information so that we may bill and collect payment from you, an insurance company, or another third party for the health care services you receive at our Center. For example, we may need to give information to your health plan regarding the services you received from our Center so that your health plan will pay us or reimburse you for the services. We also may tell your health plan about a treatment you are going to receive in order to obtain prior to approval for the services or to determine whether your health plan will cover the treatment.
3. Health care operations. We may use or disclose your health information to perform certain functions within our Center. These uses or disclosures are necessary to operate our Center and to make sure that our clients receive quality care. For example, we may use your health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may combine health information about many of our clients to determine whether certain services are effective or whether additional services should be provided. We may combine health information about many of our clients to determine whether certain services are effective or whether additional services should be provided. We may disclose your health information to physicians, nurses, nursing assistants, medication aides, rehabilitation therapy specialists, technicians, medical and nursing students, and other personnel for review and learning purposes. We also may combine health information with information from other health care providers or facilities to compare how we are doing and see where we can make improvements in the care and services offered to our clients. We may remove information that identifies you from this set of health information so that others may use the information to study health care and health care delivery without learning the specific identities of our clients.
a. Fundraising activities. W may contact you or your designated representative as part of a fundraising effort. If you do not want our Center to contact you for these fundraising purposes, you must notify the Adult Day Care office in writing.
4. Center Newsletter and Directory.
a) We may use or disclose certain limited information about you in our Center newsletter while you are a client at our Center. This information may include your name, and information contained in your social history.
b) We may use or disclose certain limited health information about you on our center directory. This information may include your name, and general condition. The directory information, except for religious affiliation, may be given to people who ask for you by name. You religious affiliation may be given to a member of the clergy.
5. Communication with Individuals involved in your care. Health professionals, using their best judgement, may disclose your health information to individuals, such as family member, other relative, close personal friend, or any other person you identify, who are involved in your care or who help pay for your care.
6. Public Health Activities. We may use or disclose your health information to public health authorities that are authorized by law to receive and collect health information for the purpose of preventing or controlling disease, injury or disability. We may use or disclose your health information for the following purposes:
i. To report deaths
ii. To report suspected or actual abuse, neglect
iii. To report adverse reactions to medications or problems with health care products
iv. To notify an individual who may have been exposed to a disease or may be at risk for spreading or contracting a disease or condition
7. Health oversight activities. We may use or disclose your health information to a health oversight agency that is authorized by law to conduct health oversight activities. These oversight activities may include audits, investigations, inspections, or licensure and certification surveys. These activities are necessary for the government to monitor and to ensure compliance with applicable state and federal laws and regulations.
8. Judicial or administrative proceedings. We may use of disclose your health information to courts or administrative agencies with the authority to hear and resolve lawsuits or disputes. We may disclose your health information pursuant to a court order, a subpoena, a discovery request, or other lawful process issued by a judge or other person involved in the dispute, but only if efforts have been made to (i) notify you of the request for disclosure or (ii) obtain an order protecting your health information.
9. Worker’s compensation. We may use or disclose your health information to worker’s compensations programs when your health condition arises out of a work-related illness.
10. Law Enforcement Official. We may use or disclose your health information in response to a request received from a law enforcement official for the following purposes:
i. In response to a court order, subpoena, warrant, summons or similar lawful process
ii. To identify or locate a missing person
iii. Regarding a victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement
iv. To report criminal conduct at our facility
v. In emergency situations, to report a crime—the location of the crime and possible victims; or the identity, description, or locations of the individual who committed the crime
11. Coroners, medical examiners, or funeral directors. We may use or disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We also may use or disclose your health information to a funeral director for the purpose of carrying out his/her necessary activities.
12. Organ procurement organization or tissue banks. If you are an organ donor, we may use or disclose your health information to organizations that handle organ procurement, transplantation, or tissue banking for the purpose of facilitating organ or tissue donation or transplantation.
13. Research. We may use or disclose your health information for research purposes under certain limited circumstances. Our Administrative Committee will review the research proposal and established protocols to ensure the privacy of your health information. In most instances, we will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address, or other identifying information.
14. To avert a serious threat to health or safety. We may disclose your health information when necessary to prevent a serious threat to the health or safety of you or other individuals. Any such use or disclosure would be made solely to the individual(s) or organization(s) that have the ability and/or authority to assist in preventing the threat.
15. Business Associates. There are some services provided in our organization through contacts with business associates. Examples include accountants, consultants, and attorneys. When these services are contracted, we may disclose your health information to our business associated 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.
16. Notification. We may use or 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, e.g. on an answering machine.
17. 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 replacement.
Although your health record is the physical property of Calhoun County Medical Care Facility/Marian E. Burch Adult Day Care Center, the information in your health record belongs to you. You have the following rights:
1. Right to inspect and copy. You or your representative has the right to inspect and copy health information that may be used to make decisions about your care. Generally, 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 to the Adult Day Care Business Office. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.
We may deny your request to inspect and copy your health information in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional selected by our Center will review your request and denial. The person conducting the review will not be the person who initially denied your request. We will comply with the outcome of this review. For more information about this right, see 45 Code of Federal Regulations (C.F.R. § 164.524.
2. Right to request an amendment. If you feel that the 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 information is kept by our Center.
To request an amendment, your request must be made in writing and submitted to the Adult Day Care Business office. We ask that you use the form provided by our Center to make such requests. For a request form, please contact the Business Office. In addition, you must provide us with 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, you must provide us with a reason that supports your request if you ask us to amend information that:
a. was not created by us, unless the person or entity that created the information is no longer available to make the amendment
b. is not part of the health information kept by or for our Center
c. is not part of the information which you would be permitted to inspect and copy
d. is accurate and complete
For more information about this right, see 45 Code of Federal Regulations
(C.F.R.) § 164.526.
3. 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, such as a family member or friend, who is involved in your care or in the payment of your care.
For example, you could ask that we not disclose information regarding a particular treatment that you received.
Although we will consider you request, please be aware that we are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment to you. For more information about this right, see 45 Code of Federal Regulations (C.F.R.) § 164.522(a).
To request restrictions, you must make your request in writing to the Adult Day Care Nurse. We ask that such requests be made in writing on a form provided by our Center. In your request, you must tell us (a) what information you want to limit; (b) whether you want to limit our use, disclosure or both; and (c) to whom you want the limits to apply (for example, disclosures to a family member).
4. Right to request confidential communications. You have the right to request that we communicate with you about your health care in a certain way or at a certain location.
To request confidential communications, you must make your request in writing to the Adult Day Care Business Office. 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. For more information about this right, see 45 Code of Federal Regulations (C.F.R.) § 164.522(b).
5. Right to a paper copy of this notice. You have the right to receive a paper copy of the Notice of Information Practices. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, contact the Adult Day Care Director.
There will be no discrimination, intimidation or retaliation to you or your representative filing a complaint.
*You may revoke an authorization to use or disclose health information, except to the extent that action had already been taken. Such a request must be made in writing.
Marian E. Burch Adult Day Care Center
Battle Creek, MI 49014
Phone: (269) 962-1750
I acknowledge that I received and understand this Privacy Notice. I understand that I have the opportunity to agree or object to use or disclosure of the following information. I further understand that the Center is under obligation to honor my requests but will make every effort to do so. Please initial your choice.
Information needed by persons not employed by Marian E. Burch Adult Day Care Center, but are involved with care or payment (or will be upon discharge) – includes family members, other relatives, and other identified by you.
________ I agree ________ I object
Information necessary to locate family and/or friends in case of an emergency.
________ I agree ________ I object
___________________________________ ________________
Signature of Client/Legal Representative Date
___________________________________ ________________
Relationship to Client Date
___________________________________ ________________
Center Representative Date