PATIENT PRIVACY NOTICE

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.

Muskegon Surgery Center respects the privacy of your “protected health information,” and is committed to maintaining our patients’ confidentiality.  This Privacy Notice is being provided to you in accordance with federal law, specifically, the Health Insurance Portability and Accountability Act (HIPAA).  This Notice informs you about the possible uses and disclosures of your protected health information. It also describes your rights and our obligations regarding your protected health information.  “Protected health information” means individually identifiable health information that we transmit or maintain in any form, including electronic or paper files. It does not include information in certain educational and employment records. This Notice applies to all your protected health information and records related to your medical care that our facility has received or created.

Muskegon Surgery Center is required by law to:

  • maintain the privacy of your protected health information;
  • provide to you this detailed Notice of our legal duties and privacy practices relating to your protected health information;
  • abide by the terms of the Notice that are currently in effect; and
  • notify you in the event your protected health information is breached, consistent with applicable rules.

I. USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION

Muskegon Surgery Center may use and disclose your protected health information for purposes of treatment, payment and health care operations without your consent. We have described these uses and disclosures below and provide examples of the types of uses and disclosures we may make in each of these categories.

A. For Treatment. We will use and disclose your protected health information in providing you with treatment and services. We may disclose your protected health information to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurse aides, physical therapists, and clinical consultants. For example, a nurse caring for you will report any change in your condition to your physician. We also may disclose protected health information to individuals who will be involved in your care after you leave the facility.

B. For Payment. We may use and disclose your protected health information so that we can bill and receive payment for the treatment and services you receive at the facility. For billing and payment purposes, we may disclose your protected health information to your representative, an insurance or managed care company, Medicare, Medicaid or another third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for a proposed treatment or service.

C. For Health Care Operations. We may use and disclose your protected health information for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use protected health information to evaluate our facility’s services, including the performance of our staff. We may also send communications to you for treatment, refill reminders for drugs or biologics that are currently being prescribed for you, case management activities, or to describe health-related products or services that we provide.

II. WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES

Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:

A. Facility Directory. Unless you object, we will include certain limited information about you in our facility directory. This information may include your name, your location in the facility, your general condition and your religious affiliation. Our directory does not include specific medical information about you. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy.

B. Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose your protected health information to a family member, relative, or close personal friend, including clergy, who is involved in your care.

C. Disaster Relief. We may disclose your protected health information to an organization assisting in a disaster relief effort.

D. As Authorized or Required By Law. We will disclose your protected health information when authorized or required by federal, state or local law to do so.

E. Public Health Activities. We may disclose your protected health information for public health activities. These activities may include, for example

• reporting to a public health or other government authority for preventing or controlling disease, injury or disability, or reporting child abuse or neglect;

• reporting to the federal Food and Drug Administration (“FDA”) concerning adverse events or problems with products for tracking products in certain circumstances, to enable product recalls or to comply with other FDA requirements;

• to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; or

• for certain purposes involving workplace illness or injuries.

F. Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your protected health information to notify a government authority if required or authorized by law, or if you agree to the report.

G. Health Oversight Activities. We may disclose your protected health information to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings. These activities are necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws.

H. Judicial and Administrative Proceedings. We may disclose your protected health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process.

I. Law Enforcement. We may disclose your protected health information for certain law enforcement purposes, including

• as required by law to comply with certain reporting requirements;

• to comply with a court order, court-ordered warrant, and/or under certain circumstances, a subpoena, summons, investigative demand or similar legal process;

• to identify or locate a suspect, fugitive, material witness, or missing person;

• when information is requested about the victim of a crime if the individual agrees or under other limited circumstances;

• to report information about a suspicious death;

• to provide information about criminal conduct occurring at the facility;

• to report information in emergency circumstances about a crime; or

• where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody.

J. Research. We may allow protected health information of patients from our own facility to be used or disclosed for research purposes provided that the researcher adheres to certain privacy protections. Your protected health information may be used for research purposes only if the privacy aspects of the research have been reviewed and approved by a special Privacy Board or Institutional Review Board, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.

K. Coroners. Medical Examiners Funeral Directors. Organ Procurement Organizations. We may release your protected health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

L. To Avert a Serious Threat to Health or Safety. We may use and disclose your protected health information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat.

M. Military and Veterans. If you are a member of the armed forces, we may use and disclose your protected health information as required by military command authorities. We may also use and disclose protected health information about foreign military personnel as required by the appropriate foreign military authority.

N. Workers’ Compensation. We may use or disclose your protected health information to comply with laws relating to workers’ compensation or similar programs.

O. National Security and Intelligence Activities; Protective Services for the President and Others. We may disclose protected health information to authorized federal Officers conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of states or to conduct certain special investigations.

P. Fundraising Activities and Your Rights to “Opt Out” of Receiving Further Communications. We may use certain protected health information to contact you in an effort to raise money for the facility and its operations. We may disclose protected health information to a foundation related to the facility so that the foundation may contact you in raising money for the facility. In doing so, we would only release contact information, such as your name, address and phone number and the dates you received treatment or services at the facility. Any fundraising materials you receive will give you the option of “opting out” of receiving further fundraising communications. We will not condition treatment or payment on your agreement to receive fundraising communications. If you do not want to receive the materials described above, please contact our Privacy Officer at (231) 733–7800 or (231) 733-7801 and request that these fundraising materials not be sent to you. If you change your mind and wish to opt back in, you may do so by contacting our Privacy Officer.

Q. Marketing and Your Rights to “Opt Out” of Receiving Further Communications. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives, or other health-related benefits, drugs, goods and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about the services we offer or to send you information about products or services that we believe may be beneficial to you. If the facility wants to enter into a relationship with another person or business that will result in the facility receiving financial remuneration, the facility will obtain a specific written authorization from you or your personal representative before using or disclosing protected health information for such marketing purposes. If you do not want to receive the materials described above or do not wish for us to sell any or your protected health information, please contact our Privacy Officer at (231) 733–7800 or (231) 733-7801 and request that these marketing materials not be sent to you and/or we will not release your protected health information.

R. Business Associates and Subcontractors. We may disclose your protected health information to a business associate or subcontractor who needs the information to perform services for our facility. We require that our business associates and subcontractors be committed to preserving the confidentially of your protected health information disclosed to them. We require all of our business associates to have an agreement with us in which they promise to use your protected health information only for permitted uses and disclosures. We also require our business associates to have the same type of agreement with all of their subcontractors.

S. Inmates. If you are under the custody of a law enforcement Officer or a correctional institution, we may disclose your protected health information to the institution or Officer.

T. Appointment Reminders. We may use or disclose protected health information to remind you about appointments. If you have an answering machine we may leave the reminder in a message.

U. Treatment Alternatives. We may use or disclose protected health information to inform you about treatment alternatives that may be of interest to you.

V. Health-Related Benefits and Services. We may use or disclose protected health information to inform you about health-related benefits and services that may be of interest to you.

III. YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES OF PROTECTED HEALTH INFORMATION

We will use and disclose your protected health information (other than as described in this Notice or required by law) only with your written Authorization. You may revoke your Authorization to use or disclose protected health information in writing, at anytime. If you revoke your Authorization, we will no longer use or disclose your protected health information for the purposes covered by the Authorization, except where we have already relied on the Authorization.

IV. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have the following rights regarding your protected health information at the facility:

A. Right to Request Restrictions. You have the right to request restrictions on our use or disclosure of your protected health information for treatment, payment or health care operations. We must comply with your request not to disclose protected health information if (1) the reason we would disclose the protected health information is to obtain payment or for operational purposes (and not for treatment purposes), and (2) the protected health information pertains solely to health care services that you, or someone on your behalf, as paid for out of pocket, in full. You also have the right to restrict the protected health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care. The facility may terminate a restriction we have previously agreed to, except when you pay in full, if we provide notice to you that we are doing so.

B. Right of Access to Protected Health Information. You have the right to inspect and obtain a copy of your medical or billing records or other written information that may be used to make decisions about your care, subject to some limited exceptions. If we maintain an electronic health record for you, then your right includes, at your option, access to the information in electronic format provided to you directly, or to an individual whom you clearly, conspicuously and specifically designate. You also have a right to receive information in a form and format that you request, if it is readily producible in that for and format; or, if not, in a readable electronic form and format as mutually agreed by you and the facility. Upon request, we will make the records available for inspection within ten days. If you request copies, we may charge a reasonable fee for our costs in copying and mailing your requested information. For information provided to you in electronic format, we may charge a fee that is no greater than the cost of labor in responding to your request.

We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied access to protected health information, in some cases you will have a right to request a review of the denial. This review would be performed by a licensed health care professional designated by the facility who did not participate in the initial decision to deny access.

C. Right to Send Protected Health Information to a Third Party. You have a right to have your protected health information sent directly to a third part, such as another individual or health care provider. To help us accomplish this, you must sign a written request that clearly identifies the third party and the address to which the information is to be sent.

D. Right to Request Amendment. You have the right to request the facility to amend any protected health information maintained by the facility if you believe it is inaccurate or incomplete for as long as the information is kept by or for the facility. You must make your request in writing and must state the reason for the requested amendment.

We may deny your request for amendment if:

• the information was not created by our facility;

• the originator of the information is no longer available to act on your request;

• the information is not part of the protected health information maintained by or for our facility;

• the information is not part of the information to which you have a right of access; or

• the information is already accurate and complete, as determined by the facility.

If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.

E. Right to an Accounting of Disclosures. You have the right to request an “accounting” of our disclosures of your protected health information. This is a listing of certain disclosures of your protected health information made by the facility or by others on our behalf, but does not include disclosures for treatment, payment and health care operations or certain other exceptions.

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 14, 2003 that is within six years from the date of your request. An accounting will include, if requested:

• the disclosure date;

• the name of the person or entity that received the information and address, if known;

• a brief description of the information disclosed;

• a brief statement of the purpose of the disclosure or a copy of the authorization or request; or

• certain summary information concerning multiple similar disclosures.

The first accounting provided within any twelve-month period will be free; for further requests within the same twelve-month period, we may charge you our costs.

F. Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

G. Right to Request Confidential Communications. You have the right to request that we communicate with you concerning protected health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number or by e-mail. We will accommodate your reasonable requests.

H. Your Rights of Notification In the Event of a Breach.  A breach is the unauthorized acquisition, access, use, or disclosure of unsecured protected health information which compromises the security or privacy of the protected health information, as defined by federal law. Protected health information is “unsecured” if it can be used, read or deciphered by an unauthorized person. If a breach happens, we will conduct a thorough risk assessment of the probability that protected health information has been compromised. We will presume that there has been a breach of your protected health information unless our risk assessment demonstrates that there is a low probability that your information has been compromised.

There are three exceptions to this rule, where:

• in good faith, a member of our workforce unintentionally acquired, accessed, used or disclosed the information under the authority of the facility or its business associate of subcontractor;

• an authorized person at the facility or its business associate or subcontractor inadvertently discloses the information to another similarly situated individual at the same facility; or

• the unauthorized person would not reasonably be able to retain the information.

The exceptions do not apply if the information received as a result of a disclosure is further acquired, accessed, used or disclosed without authorization by any person.

The facility will notify or arrange to notify you if we believe your protected health information was accessed, acquired, or disclosed as a result of the breach. You have a right to be notified without delay, and in no case later than 60 calendar days after the breach is discovered. The notice will include a brief description of:

• what happened;

• the types of information that were involved (such as name, Social Security number, date of birth, home address, account number, diagnosis, disability code, or other information);

• steps you should take to protect yourself from potential harm;

• what we are doing to investigate the breach, mitigate harm to you, and protect against any further breaches; and

• contact information for you to ask questions or learn additional information.

V. COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint verbally or in writing with our Privacy Officer at:

MUSKEGON SURGERY CENTER
1400 Mercy Drive
Muskegon, MI 49444-1836
ATTN: Privacy Officer
 (231) 733-7800

You may also file a complaint with the Office of Civil Rights in the U.S. Department of Health and Human Services.  Muskegon Surgery Center will not retaliate against you for filing a complaint in good faith.

VI. CHANGES TO THIS NOTICE

Muskegon Surgery Center is required by law to maintain the privacy of your health information and to provide you with this Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time.  We will promptly revise this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all protected health information already received and maintained by the facility as well as for all protected health information we receive in the future. We will make the notice available to you on request on or after the effective date of the revision. We will post the notice in a clear and prominent location at the facility and have copies available at the facility for individuals who request to take a copy with them.

VII. FOR FURTHER INFORMATION

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Privacy Officer at 231-733-7800 or 231-733-7801.

VIII. EFFECTIVE DATE

Effective date of notice: May 28, 2013