Notice of Privacy Practices
We at Trinity Home Health Services (THHS) agencies 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.
Our agency 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 we will use and disclose your PHI.
This Notice applies to the delivery of health care by our
THHS agencies. This Notice also applies to the utilization
review and quality assessment activities of Trinity Health
and THHS/agencies as a member of Trinity Health, a Catholic
health care system with facilities in 7 states.
I. Permitted Use or Disclosure
A. Treatment: The agency will use and disclose your PHI in
the provision and coordination of health care to carry out
treatment functions.
- The Agency 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.
- THHS agencies are Catholic sponsored health care providers.
Spiritual care providers are sometimes members of hospice
interdisciplinary teams that use your medical information
to provide health care services to clients receiving hospice
services.
- Different departments will share medical information
about you in order to coordinate specific services, such
as lab work, x-rays and prescriptions.
- The agency also will disclose your medical information
to people or entities that will be involved in your medical
care after you leave our services, such as family members
and others who will provide services that are part of your
care.
- The agency 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.
- The agency will use and disclose your PHI to inform you
of, or recommend possible treatment options or alternatives
that will be of interest to you.
- The agency will use and disclose PHI to contact you as
a reminder that you have an in-home visit scheduled.
- If you are an inmate of a correctional institution or
under the custody of a law enforcement officer, the agency
will disclose your PHI to the correctional institution or
law enforcement official.
B. Payment: The agency 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.
- The agency will disclose PHI to collection agencies and
other subcontractors engaged in obtaining payment for care.
C. Health Care Operations: The agency 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 the agency, and for educational purposes.
¨ For instance, the agency 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.
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: The agency may use and may also
disclose some of your PHI to a related foundation for certain
fund raising activities. For example, the agency may use
your demographic information (e.g., name, address and other
contact information, age, gender, and insurance status)
and the dates the agency provided service to you. Any communication
sent to you will let you know how you may opt out of receiving
similar communications in the future. The agency may disclose
limited PHI to a company contracted to conduct agency fundraising.
This company will use your PHI only for the purposes of
agency fund raising. (If you wish to opt-out, you may do
so by contacting the Executive Director/Director Designee
at the agency or the Privacy Official at THHS 248.305.7918.)
- Medical Research: The agency may disclose your PHI without
your Authorization 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: the agency
may 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.
The agency will also send you information based on your
own health concerns. The agency 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.
E. More Stringent State and Federal Laws: The State law of
Michigan is more stringent than HIPAA in several areas. State
law is more stringent when the individual is entitled to greater
access to records than under HIPAA. The agency will continue
to abide by these more stringent state and federal laws. The
federal laws 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.
In Michigan patients have more rights of access to behavioral
health information under Michigan law than under HIPAA. Minors
in Michigan have more rights to confidentiality and protection
of certain information (reproductive health, behavioral health
and substance abuse) than under HIPAA.
II. Permitted Use or Disclosure with an Opportunity for
You to Agree or Object
A. Family/Friends: The agency will disclose PHI about you
to a friend or family member who is involved in your medical
care. The agency will also give information to someone who
helps you pay for your care. In addition, the agency 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. Spiritual Care: If you are a hospice patient, a spiritual
care provider may consult regarding your care. Spiritual care
providers are members of the health care team at the hospice.
You have a right to request that your name not be given to
any member of the clergy.
C. Promotional Communications: The agency 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. THHS agencies may
maintain a database of individuals for promotional communications,
disease management, health promotion and fundraising purposes.
This database includes individuals to whom the agency previously
may have sent health improvement materials and news about
the agency and also individuals who have donated to the agency
or who have expressed an interest in donating to the agency
or other health-related activities. You may be included in
this database. THHS may send information to the individuals
in this database about the programs and services of THHS agencies.
If you wish to be deleted from this database, you may notify
the Privacy Official of THHS.
D. Media Conditions Reports: The agency 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: THHS agencies are not permitted to provide
your PHI to any other person or company for marketing to you
of any products or services other than the agency’s
products or services unless you have signed an authorization.
B. Research: The agency will 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, the agency may require that you sign an authorization
to allow the researchers to use or disclose your PHI for this
research.
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.
IV. Use or Disclosure Permitted by Public Policy or Law
without your Authorization
A. Law Enforcement Purposes: The agency 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.
Required by Law: The agency will disclose PHI about you when
required by federal, state or local law to make reports or
other disclosures. The agency also will make disclosures for
judicial and administrative proceedings such as lawsuits or
other disputes in response to a court order or subpoena. The
agency will disclose your medical information to government
agencies concerning victims of abuse, neglect or domestic
violence. The agency 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. The agency will make
certain disclosures that are required in order to comply with
workers’ compensation or similar programs.
B. Coroners, Medical Examiners, Funeral Directors: The agency
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. The agency will also disclose
your medical information to funeral directors as necessary
to carry out their duties.
C. Organ Procurement: The agency will disclose PHI to an
organ procurement organization or entity for organ, eye or
tissue donation purposes.
D. Health or Safety: The agency will use and disclose PHI
to avert a serious threat to health and safety of a person
or the public. The agency will use and disclose PHI to Public
Health Agencies for immunizations, communicable diseases,
etc. The agency 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
Although agencies must maintain all records concerning your
care and treatment, 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.
The agency 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 the
agency 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;
- The agency 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, the agency will allow the review of its decision
by a health care professional that the agency 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 the agency. The agency will respond to your
request within 30 days of its receipt. If the agency cannot,
the agency will notify you in writing to explain the delay
and the date by which we will act on your request. In any
event, the agency will act on your request within 60 days
of its receipt.
B. Right to Amend: You have the right to amend your PHI for
as long as the agency maintains it. However, the agency will
deny your request for amendment if:
- The agency 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
- The information is accurate and complete.
If the agency denies your request for changes in your PHI,
we will notify you in writing with the reason for the denial.
The agency will also inform you of your right to submit a
written statement disagreeing with the denial. You may ask
that the agency include your request for amendment and the
denial any time that the agency discloses the information
that you wanted changed. The agency 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 the Agency, including your reason to support the requested
amendment. The agency will respond to your request within
60 days of its receipt. If the agency cannot, the agency will
notify you in writing to explain the delay and the date by
which the agency will act on your request. In any event, the
agency 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 the agency
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.
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 the agency. You must include the
time period of the accounting, which may not be longer than
6 years. The agency will respond to your request within 60
days from its receipt. If the agency cannot, the agency will
notify you in writing to explain the delay and the date by
which the agency will act on your request. In any event, the
agency will act on your request within 90 days of its receipt.
In any given 12-month period, the agency 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.
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;
- Restricting specific information to only specified family
members, relatives, close personal friends or other individuals
involved in your care; or
- Limited information in the facility directory. For example,
you may ask that your information not be provided to anyone
but your designated caregiver. The agency will consider
your request but is not required to agree to the requested
restrictions unless required by state law.
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 the agency contact you at specific times.
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.
VI. Complaints
If you believe your privacy rights have been violated, you
may file a complaint with the agency or with the Secretary
of the Department of Health and Human Services. To file a
complaint with the agency, please contact the agency Privacy
Officer. All complaints must be submitted in writing directly
to the agency Privacy Official. We assure you that there will
be no retaliation for filing a complaint.
VII. Sharing and joint use of your Health Information
In the course of providing care to you and in furtherance
of THHS agencies’ mission to improve the health of the
community, the agency will share your PHI with other organizations
as described below who have agreed to abide by the terms described
below:
A. Medical Staff: Your physician(s), agency Medical Director
(where applicable) and agency participate together in an organized
health care arrangement to deliver health care to you. The
agency, Medical Directors and your physician(s) 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 the agency. Physicians, Medical Directors and allied
health care providers who are members of the agency team will
have access to and use your PHI for treatment, payment and
health care operations purposes related to your care within
the agency. The agency will disclose your PHI to these physicians
and allied health professionals for payment, treatment and
health care operations.
B. Business Associates: The agency will 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 THHS agencies.
Whenever an arrangement between the agency 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:
THHS agencies, members 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. As a part of Trinity Health,
a national Catholic health care system, THHS agencies and
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 the agency and/or for the health care
operations permitted by HIPAA with respect to our mutual patients.
VIII. Additional Information
For further information regarding the issues covered by this
Notice of Privacy Practice, please contact your agency manager
as listed on your Rights and Responsibilities Statement.
XI. Changes to this Notice
THHS agencies will abide by the terms of the Notice currently
in effect. The agency reserves the right to change the terms
of its Notice and to make the new Notice provisions effective
for all PHI that it maintains. The agency will provide you
with the revised Notice at your first visit following the
revision of the Notice.
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