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PRIVACY.

TRINITY HEALTH
NOTICE OF PRIVACY PRACTICES
ST JOSEPH MERCY HOSPITAL—OAKLAND

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.

We at St. Joseph Mercy Hospital Oakland (SJMO) 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.

SJMO understands that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how SJMO may use and disclose your PHI.

This Notice applies to the delivery of health care by SJMO and its medical staff in the main hospital, outpatient departments, outpatient facilities, clinics, our Physician Network offices, our Retail Pharmacy, and all related services. This Notice also applies to the utilization review and quality assessment activities of Trinity Health and SJMO as a member of Trinity Health, a Catholic health care system with facilities in seven states.

Permitted Use or Disclosure

  1. Treatment: SJMO will use and disclose your PHI in the provision and coordination of health care to carry out treatment functions.
    • SJMO may 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.
    • SJMO is a Catholic-sponsored health care provider. Spiritual care providers are members of our care staff and may be a part of SJMO’s team of care providers who use your medical information to provide health care services to you when you are in SJMO’s facilities.
    • Different departments may share medical information about you in order to coordinate specific services, such as lab work, x-rays and prescriptions.
    • SJMO also may disclose your medical information to people or entities outside SJMO who will be involved in your medical care after you leave SJMO, such as family members, clergy and others who will provide services that are part of your care.
    • SJMO may 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.
    • SJMO may use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that may be of interest to you.
    • SJMO may use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at SJMO.
    • If you are an inmate of a correctional institution or under the custody of a law enforcement officer, SJMO will disclose your PHI to the correctional institution or law enforcement official.
  2. Payment: SJMO may 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 may 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 may include copies or excerpts of your medical records which are necessary for payment of your account. It may also include sharing the necessary information to obtain pre-approval for payment for treatment from your health plan.
    • SJMO may disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.
  3. Health Care Operations: SJMO 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 SJMO, and for educational purposes.
    • For instance, SJMO may 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.
  4. 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: SJMO may use certain demographic information (name, address, phone, e-mail, gender, age, type of insurance, date of service) to contact you in the future to raise money for SJMO. The money raised will be used to expand and improve the services and programs provided to our community. In addition, SJMO may choose to include information about fundraising practices in newsletters and may post the information in fund development and foundation offices. SJMO may disclose limited PHI to a company contracted to conduct fundraising for SJMO. This company will use your PHI only for the purposes of fundraising for SJMO. If you do not wish to be contacted, you may notify the Manager of Fund Development, St. Joseph Mercy Oakland, 44405 Woodward Avenue, Pontiac, Michigan, 48341.
    • Medical Research: SJMO may disclose your PHI 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: SJMO may use and disclose some of your PHI for certain health promotion activities. For example, your name and address may be used to send you newsletters or general communications. SJMO may also send you information based on your own health concerns. SJMO 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.
    • Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards or letters).
  5. More Stringent State and Federal Laws: The state law of Michigan is more stringent than HIPAA in several areas. Michigan 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. SJMO will continue to abide by these more stringent state and federal laws. Federal laws that are more stringent are the Federal Privacy Act and the Children’s Online Privacy Protection Act. State laws that are more stringent are: (1) MCL §333.1707, which restricts third party’s access to a minimum necessary standard for mental health records; (2) MCL §333.9132; MCL §333.6121; and MCL §333.5127, which are laws that protect the privacy of minors seeking treatment for reproductive health, mental health and substance abuse treatment; and (3) MCL §333.5133 and MCL §333.5431 that require specific consents for genetics and HIV testings. This list will be changed if these laws are amended or other laws are added.

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

  1. Family/Friends: SJMO may disclose PHI about you to a friend or family member who is involved in your medical care. SJMO may also give information to someone who helps you pay for your care. In addition, SJMO may 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.
  2. SJMO Patient Location Listing: SJMO will include certain limited information about you in the SJMO Patient Location Listing while you are a hospital patient at SJMO. This information will include your name, location in SJMO, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation. This is so your family and friends can visit you in SJMO and know how you are doing. The patient location listing information, except for your religious affiliation, will also be disclosed to people who ask for you by name. You have the right to request that your name not be included in SJMO Patient Location Listing. If you request to opt out of the SJMO Patient Location Listing, we cannot inform visitors of your presence, location or general condition.
  3. Spiritual Care: Patient Location Listing information, including your religious affiliation, may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. Your name, location and general condition may be disclosed to members of the religious community. A spiritual care provider may be called in to consult regarding your care. Spiritual care providers are members of the health care team at SJMO. You have a right to request that your name not be given to any member of the clergy.
  4. Promotional Communications: SJMO 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. SJMO does maintain a database of individuals for promotional communications, disease management, health promotion and fundraising purposes. This database includes individuals to whom SJMO may have sent health improvement materials and news about SJMO previously and also individuals who have donated to SJMO or who have expressed an interest in donating to SJMO or other health-related activities. You may be included in this database. SJMO sends information to the individuals in this database about the programs and services of SJMO. If you wish to be deleted from this database, you may notify the Marketing Department at 44405 Woodward Avenue, Pontiac, Michigan, 48341.
  5. Media Conditions Reports: SJMO 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".

Use or Disclosure Requiring Your Authorization

  1. Marketing: SJMO is not permitted to provide your PHI to any other person or company for marketing to you of any products or services other than SJMO’s products or services unless you have signed an authorization.
  2. Research: SJMO may 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, SJMO may require that you sign an authorization to allow the researchers to use or disclose your PHI for this research.
  3. 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 or the written authorization of your personal representative after positive identification. Written authorizations will let you know why we are using your PHI. You have the right to revoke an authorization at any time.

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

  1. Law Enforcement Purposes: SJMO 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.
  2. Required by Law: SJMO will disclose PHI about you when required by federal, state or local law to make reports or other disclosures. SJMO also will make disclosures for judicial and administrative proceedings such as lawsuits or other disputes in response to a court order or subpoena. SJMO will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violence. SJMO 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. SJMO will make certain disclosures that are required in order to comply with workers’ compensation or similar programs.
  3. Coroners, Medical Examiners, Funeral Directors: SJMO may disclose your PHI to a coroner or medical examiner. For example, this may be necessary to identify a deceased person or to determine a cause of death. SJMO will also disclose your medical information to funeral directors as necessary to carry out their duties.
  4. Organ Procurement: SJMO may disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes.
  5. Health or Safety: SJMO may use and disclose PHI to avert a serious threat to health and safety of a person or the public. SJMO may use and disclose PHI to Public Health Agencies for immunizations, communicable diseases, etc. SJMO may 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. 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. If you wish to opt-out, you may do so by contacting the SJMO Privacy Officer at 248-858-3184.

Your Health Information Rights
Although we at SJMO must maintain all records concerning your hospitalization and treatment by SJMO, you have the following rights concerning your PHI:

  1. 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: information that will be used in a civil, criminal or administrative action or proceeding, and where prohibited or protected by law. SJMO may 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 SJMO 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.
    • SJMO 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.
    • Under other limited circumstances. In these instances, however, SJMO will allow the review of its decision by a health care professional that SJMO has chosen. This person will not have been involved in the original decision to deny your request.
    • You agree to pay a reasonable copying charge. You must make your requests to access and copy your PHI in writing to SJMO. SJMO will respond to your request within 30 days of its receipt. If SJMO cannot, SJMO will notify you in writing to explain the delay and the date by which we will act on your request. In any event, SJMO will act on your request within 60 days of its receipt.
  2. Right to Amend: You have the right to amend your PHI for as long as SJMO maintains it. However, SJMO may deny your request for amendment if:
    • SJMO 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).
    • The information is accurate and complete.
  3. If SJMO denies your request for changes in your PHI, SJMO will notify you in writing with the reason for the denial. SJMO will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that SJMO include your request for amendment and the denial any time that SJMO discloses the information that you wanted changed. SJMO may prepare a rebuttal to your statement of disagreement and will provide you with a copy. You must make your request for amendment of your PHI in writing to SJMO. SJMO will respond to your request within 60 days of its receipt. If SJMO cannot, SJMO will notify you in writing to explain the delay and the date by which SJMO will act on your request. In any event, SJMO will act on your request within 90 days of its receipt.
  4. Right to an Accounting: You have a right to receive an accounting (listing) of the disclosures of your PHI that SJMO made, except for the following disclosures:
    • To carry out treatment, payment or health care operations.
    • 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.
  5. 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 SJMO. You must include the time period of the accounting, which may not be longer than 6 years. SJMO will respond to your request within 60 days from its receipt. If SJMO cannot, SJMO will notify you in writing to explain the delay and the date by which SJMO will act on your request. In any event, SJMO will act on your request within 90 days of its receipt.

    In any given 12-month period, SJMO 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.
  6. 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.
    • Restricting specific information to only specified family members, relatives, close personal friends or other individuals involved in your care.
    • Limited information in the Patient Location Listing. 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. SJMO will consider your request but is not required to agree to the requested restrictions.
  7. 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 SJMO contact you at work or by mail.
  8. 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.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with SJMO or with the Secretary of the Department of Health and Human Services. To file a complaint with SJMO, please contact SJMO’s Privacy Officer or HIPAA Coordinator at 248-858-3184 to receive the Privacy Complaint form. All complaints must be submitted in writing directly to SJMO’s Privacy Officer. SJMO assures you that there will be no retaliation for filing a complaint.

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

  1. Medical Staff: The medical staff and SJMO participate together in an organized health care arrangement to deliver health care to you at SJMO. Both SJMO 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 SJMO. Physicians and allied health care providers are members of SJMO’s medical staff and will have access to and use your PHI for treatment, payment and health care operations purposes related to your care within SJMO. SJMO will disclose your PHI to the medical staff for payment, treatment and health care operations.
  2. Business Associates: SJMO may use and disclose your PHI to business associates contracted to perform business functions on its behalf, including Trinity Health, its parent who performs certain business functions for SJMO. Whenever an arrangement between SJMO and another company involves the use or disclosure of your PHI, that business associate will be required to keep your information confidential.
  3. Membership in Trinity Health: SJMO, 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 health care operations. As a part of Trinity Health, a national Catholic health care system, SJMO 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 SJMO and/or for the health care operations permitted by HIPAA with respect to our mutual patients.

Additional Information
For further information regarding the issues covered by this Notice of Privacy Practice, please contact our Privacy Officer or HIPAA Coordinator at (248) 858-3184.

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