D. A. BLODGETT – ST. JOHN’S NOTICE OF PRIVACY PRACTICES This notice describes how medical and other confidential information about you that is contained in your case record may be used and disclosed and how you can view the information in your case record. Please review this notice carefully. This notice is being provided to you pursuant to the federal law known as HIPAA and an amendment to that law, known as HITECH. If you have any questions about this notice, please contact our Privacy Officer: Donna Tefft at 805 Leonard NE Grand Rapids, MI 49503; 616 451-2021; [email protected]. Other statutes and regulations, including the Michigan Mental Health Code and Part 2 of Title 42 of the Code of Federal Regulations (CFR) may further restrict our use and disclosure of Protected Health Information. When that is the case, the greater restrictions or protections apply. Protected Health Information (PHI) is all individually identifiable health information that is created or received by D. A. Blodgett – St. John’s that relates to your past, present or future physical or mental health condition, the provision of health care services and payment for those services. Examples of PHI includes: your name, address, phone number and date of birth; your diagnosis (reason you are receiving treatment) and your treatment plan and goals. D. A. Blodgett – St. John’s is required by law to maintain the privacy of your PHI and to abide by the terms of this Notice. We reserve the right to change the terms of our Privacy Practices at any time and will provide you with a copy of the revised Notice by posting it on our website. If you request it, we will send you a revised copy or provide you a copy at your next appointment at no cost to you. OUR PLEDGE TO YOU REGARDING YOUR PHI We understand that your health and medical information about you is personal. We are required by law to maintain the privacy of your PHI, to notify you following a breach of your unsecured PHI, and to provide you with this notice of our legal duties and privacy practices. This notice applies to the medical records and health and medical information we maintain concerning all services you receive from D. A. Blodgett – St. John’s. This notice will tell you about the ways in which we may use and disclose (share with others) your PHI. It also describes our obligation and your rights regarding the use and disclosure of your PHI. HOW WE MAY USE AND DISCLOSE YOUR PHI We may use and disclose PHI for a variety of reasons. We have a limited right to use and/or disclose your PHI without your authorization for purposes of treatment, payment or our health care operations. Other uses and disclosures require your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. Subject to the limitations of the Michigan Mental Health Code, and Title 42, Part 2 of the Code of Federal Regulations, we may use or disclose your PHI without your authorization as follows:
ThisnoticeisbeingprovidedtoyoupursuanttothefederallawknownasHIPAAandanamendmenttothatlaw,knownasHITECH.Ifyouhaveanyquestionsaboutthisnotice,pleasecontactourPrivacyOfficer:DonnaTefftat805LeonardNEGrandRapids,MI49503;616451-2021;[email protected],includingtheMichiganMentalHealthCodeandPart2ofTitle42oftheCodeof Federal Regulations (CFR) may further restrict our use and disclosure of Protected Health Information.Whenthatisthecase,thegreaterrestrictionsorprotectionsapply.ProtectedHealthInformation(PHI)isallindividuallyidentifiablehealthinformationthatiscreatedorreceivedbyD.A.Blodgett–St.John’sthatrelatestoyourpast,presentorfuturephysicalormentalhealthcondition,theprovisionofhealthcareservicesandpaymentforthoseservices.ExamplesofPHIincludes:yourname,address, phone number and date of birth; your diagnosis (reason you are receiving treatment) and yourtreatmentplanandgoals.D.A.Blodgett–St.John’sisrequiredbylawtomaintaintheprivacyofyourPHIandtoabidebythetermsofthisNotice.WereservetherighttochangethetermsofourPrivacyPracticesatanytimeandwillprovideyouwithacopyoftherevisedNoticebypostingitonourwebsite.Ifyourequestit,wewillsendyouarevisedcopyorprovideyouacopyatyournextappointmentatnocosttoyou.
WemayuseanddisclosePHIforavarietyofreasons.Wehavealimitedrighttouseand/ordiscloseyourPHIwithoutyourauthorizationforpurposesoftreatment,paymentorourhealthcareoperations.Otherusesanddisclosures require yourwritten authorization unless the law permits or requires us tomake the use ordisclosurewithoutyourauthorization.Subject to the limitationsof theMichiganMentalHealthCode, andTitle 42, Part 2 of theCodeof FederalRegulations,wemayuseordiscloseyourPHIwithoutyourauthorizationasfollows:
ForCareorTreatment:YourPHImaybeusedanddisclosedtothosewhoare involved inyourcare for thepurpose of providing, coordinating, or managing your services. This includes consultation with clinicalsupervisorsorotherteammembers.YourauthorizationisrequiredtodisclosePHItoanyothercareprovidernotcurrentlyinvolvedinyourcare.WemayuseyourPHI,suchasyourname,phonenumberandaddresstocontactyoutoremindyouofyourappointment.ForPayment:YourPHImaybeusedanddisclosedtoanypartiesthatareinvolvedinpaymentforyourcareortreatment.ThisincludesbutisnotlimitedtoHealthPlanSponsor,Medicaid,andprivateinsurance.Ifyoupayfor your care or treatment completely out of pocket with no use of any insurance, you may restrict thedisclosureofyourPHIforpayment.For Business Operations:We may use or disclose your PHI as needed in order to support our businessactivitiesincluding,butnotlimitedto,qualityassessmentactivities,employeereviewactivities,licensing,andconductingorarrangingforotherbusinessactivities.WemayalsodisclosePHIinthecourseofprovidingyouwith appointment information or leaving messages on your phone or at your home about questions youasked.FundraisingandOtherCommunications:WemayusepartsofyourPHItoofferyouinformationthatmaybeof interesttoyousuchassendingyounewslettersorother informationaboutactivities. Ifweevercontactyou to raise funds, we will inform you of our intention and your right to opt out of receiving suchcommunications.Business Associates and Subcontractors: We may contract with individuals and organizations known asBusiness Associates to perform various functions or provide certain services. In order to perform thesefunctions or provide these services, Business Associatesmay receive, create,maintain, use and/or discloseyourPHI,butonlyaftertheysignanagreementwithusrequiringthemtoimplementappropriatesafeguardsregardingyourPHI. SimilarlyaBusinessAssociatemayhireaSubcontractor toassist. IfaSubcontractor ishired, TheBusinessAssociatemaynotdisclose yourPHI to the Subcontractoruntil after the Subcontractorenters intoa SubcontractorAgreementwith theBusinessAssociate thatalso requires theSubcontractor tosafeguardyourPHI.PublicHealth:WemaydisclosepartsofyourPHItothePublicHealthDepartmentwhenthelawrequiresustodoso.Thisdisclosurewouldonlybemadeforthepurposeofcontrollingdisease,injuryordisability.HealthOversight Entities: Wemaydisclose yourPHI to agencies that are responsible formaking sureourservicesmeet quality standards. Theymay need your PHI for activities such as audits, investigations andinspections.Law Enforcement: We will disclose your PHI when required to do so by federal, state or local law. Forexample,wemaydisclosePHIinthecourseofanycourtoradministrativeproceedingifweareorderedtodoso and/or meet legal requirements. We may also disclose PHI for law enforcement purposes, such asinvestigationofacrime,butonlyifsuchdisclosurescomplywithMichiganlaw.FoodandDrugAdministration:WemaydiscloseyourPHIiftheFoodandDrugAdministrationrequiresit:forexample,toreportadverseeventsorproductdefectsorproblems.Coroners orMedical Examiners: Wemay disclose PHI to a coroner ormedical examiner for identificationpurposes,determiningcauseofdeathorforthecoronerormedicalexaminertoperformotherduties.
ResearchOrganizations/Individuals:WemaydiscloseyourPHItoresearchersonlywithyourauthorization.WorkersCompensation:WemaydiscloseyourPHItocomplywithMichiganWorkers’Compensationlaws.CorrectionalFacilities:WemayuseordiscloseyourPHIifyouareaninmateofacorrectionalfacilityandD.A.Blodgett–St.John’screatedorreceivedyourPHIinthecourseofprovidingcaretoyou.DepartmentofHealthandHumanServices(HHS):WemustreleaseyourPHItoHHSsotheycanmakesureweare following the law. Wealso releaseyourPHI ifwesuspect theremayhavebeenchildorvulnerableadultabuseorneglect. FederalandStateLawsrequirethesereports. Michigan lawdoesnotrequireustonotifyyouwhenwemakeareportaboutabuseorneglect.Militaryand/orVeteran’sAdministration: Ifyouareamemberofthearmedforces,wemayreleaseyourPHIasrequiredbymilitarycommandauthorities.WemayalsoreleasePHIaboutforeignmilitarypersonneltothe appropriate foreignmilitary authority. Wemay also release PHI for you to receive and or coordinatebenefits.AsRequiredbyLaw:WewilldiscloseyourPHIwhenrequiredtodosobyfederal,stateorlocallaw.
YOURRIGHTSREGARDINGYOURPHIYouhavethefollowingrightsregardingyourPHIwhichwemaintain:Toexerciseanyoftheserights,pleasesubmityourrequestinwritingtoourPrivacyOfficer:YourChoices: For certainhealth information, you can tell us your choices aboutwhatwe share.Youmaydecideifyouwantinformationsharedwithyourfamily,closefriendsorothersinvolvedinpaymentforyourcare.Youalsohavetherighttodecideifyouwantustoshareinformationinadisasterreliefsituation.Ifyouare not able to tell us your preference, for example, if you are unconscious, wemay go ahead and shareinformation ifwebelieve it is in yourbest interest. Wemayalso share your informationwhenneeded tolessenaseriousandimminentthreattohealthorsafety.Ifyouhaveaclearpreferenceforhowweshareyourinformationinthesesituationstelluswhatyouwantustodo,andwewillfollowyourinstructions.RighttoInspectandReceiveaCopyofyourPHI:Youhavetherighttorequestaccesstoyourcaserecordforaslongaswemaintainit.Youhavetherighttoinspecttheinformationaswellastherighttoacopyoftheinformation.Youmayrequestthattheinformationbesenttoyouorathirdparty.Youmustsubmitarequestfor access in writing to our Privacy Officer. If you request a copy of the information, we may charge areasonable fee for the costs of copying,mailing or other supplies associatedwith your request (such as athumbdriveinthecaseofarequestforelectronicinformation).IfwemaintainyourPHIelectronically,wewillprovideyouaccesstotheinformationinanelectronicformandformatthatyourequest.Wemaydenyyourrequesttoinspectandcopyincertaincircumstances.IfyouaredeniedaccesstomedicalinformationyoumayrequestthatthedenialbereviewedbycontactingourPrivacyOfficer.Under federal law you may not see or copy the following that may be contained in your record:psychotherapynotes; informationgatheredforuseincourtorathearings;PHIthatiscoveredbyalawthatstatesyoumaynotseeitand/orinformationassignedordevelopedaspartofapeerreviewfunction.Right toAmend:If you feel that thePHIwehave about you is incorrect or incomplete, youmay askus toamend the information. To request an amendment, your requestmust bemade inwriting and youmust
provide a reason that supports your requests. All requests to amend informationmust bedirected to theAgency’sPrivacyOfficer.Wemaydenyyourrequestforanamendmentofinformationthat:
RighttoRequestRestrictions:YouhavetherighttorequestarestrictionorlimitationontheuseordisclosureofyourPHIforservices,payment,orbusinessoperations.YoualsohavetherighttorequestalimitonyourPHIthatwedisclosetosomeonewhoisinvolvedinyourcaresuchasafamilymemberorfriend.Torequestrestrictions,youmustmakeyourrequestinwritingtothePrivacyOfficerandmustinclude:whatinformationyouwanttolimit,whetheryouwanttolimitouruse,disclosureorboth,andtowhomyouwantthelimitstoapply.Wearenotrequiredtoagreetoyourrequest.WewillallowyourPHItobeusedorreleasedifpermittedbylawandifyourtreatmentprofessionalbelievesitisinyourbestinterest.Ifyourtreatmentprofessionaldoesagree to your request, we may not use or release your PHI unless it is needed to provide emergencytreatment.Pleasediscussanyrestrictionyouwishtorequestwithyourtreatmentprofessional.RighttoRequestConfidentialCommunication:YouhavetherighttorequestthatwecommunicatewithyouaboutPHImattersinacertainwayoratacertainlocation.Forexampleyoucanaskthatweonlycontactyouatwork,orthatwedonotleaveamessageonyourhomephone.PleasemaketheserequestsinwritingtoyourtreatmentprofessionalandourPrivacyOfficer.Wewillnotaskyouthereasonforyourrequestandwillaccommodateallreasonablerequests.RighttoanAccountingofDisclosures:YouhavetherighttorequestanaccountingofcertaindisclosuresthatwemakeofyourPHI.Theaccountingwillnotincludedisclosurestocarryouttreatment,paymentandhealthcareoperations,disclosurestoyouaboutyourownPHI,disclosurespursuanttoanindividualauthorization,orother disclosures as set forth in HIPAA privacy policies and procedures. To request an accounting ofdisclosures,youmustsubmityourrequest inwritingtothePrivacyOfficer. Yourrequestmuststateatimeperiodwhichmaynotbelongerthan6years.Yourrequestshouldindicateinwhatformyouwantthelist(ie:electronicorpaper).Wemaychargeyouareasonablefeeifyourequestmorethanoneaccountinginany12-monthperiod.RighttoaCopyofthisNotice:Youhavetherighttoapapercopyofthisnoticeatanytimeatnocosttoyou.ToobtainapapercopyofthisnoticecontactyourtreatmentprofessionalorourPrivacyOfficer.
WEBSITEPRIVACYAnypersonalinformationyouprovideuswithviaourwebsite,includingyoure-mailaddress,willneverbesoldorrentedtoanythirdpartywithoutyourexpresspermission.Ifyouprovideuswithanypersonalorcontactinformation inorder to receive anything fromus,wemay collect and store that personal data.Wedonotautomatically collect yourpersonal e-mail address simplybecause you visit our site. In some instances,wemaypartnerwithathirdpartytoprovideservicessuchasnewsletters,surveystoimproveourservices,healthorcompanyupdates,andinsuchcase,wemayneedtoprovideyourcontactinformationtosaidthirdparties.This information, however, will only be provided to these third-party partners specifically for thesecommunications,andthethirdpartywillnotuseyourinformationforanyotherreason.Whilewemaytrackthevolumeofvisitorsonspecificpagesofourwebsiteanddownloadinformationfromspecificpages,thesenumbersareonlyusedinaggregateandwithoutanypersonalinformation.Thisdemographicinformationmaybesharedwithourpartners,butitisnotlinkedtoanypersonalinformationthatcanidentifyyouoranyvisitortooursite.Oursitemaycontainlinkstootheroutsidewebsites.Wecannottakeresponsibilityfortheprivacypoliciesorpracticesofthesesitesandweencourageyoutochecktheprivacypracticesofallinternetsitesyouvisit.Whilewemakeeveryeffort toensure thatall the informationprovidedonourwebsite iscorrectandaccurate,wemakenowarranty, expressor implied, as to the accuracy, completenessor timeliness, of theinformationavailableonoursite.Wearenotliabletoanyoneforanyloss,claimordamagescausedinwholeorinpart,byanyoftheinformationprovidedonoursite.Byusingourwebsite,youconsenttothecollectionanduseofpersonalinformationasdetailedherein.AnychangestothisPrivacyPolicywillbemadepubliconthissitesoyouwillknowwhatinformationwecollectandhowweuseit.
COMPLAINTSIfyoubelievewehaveviolatedyourprivacyrights,youhavetherighttofileacomplaintinwritingwithourPrivacyOfficer,DonnaTefft805LeonardNEGrandRapids,MI49503-1138;616451-2021;dtefft@dabsj.orgorwiththeU.S.DepartmentofHealthandHumanServicesOfficeforCivilRightsbysendinga letterto200Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visitingwww.hhs.gov/ocr/privacy/hipaa/complaints/. D.A. Blodgett – St. John’swill not retaliate against you forfilingacomplaint.
CHANGESTOTHISNOTICEWe reserve the right to change this notice. We reserve the right tomake the revised or changed noticeeffectiveforPHIwealreadyhaveaboutyouaswellasanyinformationwereceiveinthefuture.ChangestothisnoticewillbepostedonourAgencywebsitewww.dabsj.org.Effective9/23/2013
ACKNOWLEDGEMENTOFRECEIPT
OF
D.A.BLODGETT–ST.JOHN’SPRIVACYPRACTICESIacknowledgethatIhavereceivedacopyofD.A.Blodgett–St.John’sPrivacyPractices,havebeenprovidedthe opportunity to ask questions, and understand how the confidential information contained in my caserecordwillbeusedanddisclosedtoothers.PrintedName: Signature: Relationship: Date: AGENCYSTAFFUSEONLY:Asignaturewasnotobtainedfrom for the following
