This notice describes how medical information may be used and disclosed and how you can get access to this information.
Please review carefully.

Providers covered by this notice
 
Northern Michigan Regional Hospital and Northern Michigan Hematology and Oncology ("we" or "us") are related entities. We are required by law to maintain the privacy of your health information, to provide you with this Notice of our legal duties and privacy practices, and to abide by the terms of this Notice currently in effect.

In addition, Northern Michigan Regional Hospital offers you care in an integrated setting with area physicians who serve on its medical staff. While working at the hospital, these medical staff members will follow the privacy practices described in this Notice. Please note that the independent doctors and independent health professional affiliates of the medical staff are not employees or agents of Northern Michigan Regional Hospital, and they may have different notices and privacy practices when working out of their own offices.

We and the medical staff physicians may share your health information for purposes of providing you with treatment, obtaining payment for medical services, and for health care operations. Examples of sharing information for purposes of treatment, payment, and health care operations are described below.

Our pledge to you

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care, bill for your care, and comply with legal requirements. This Notice applies to all of the records of your care that we maintain, whether made by our staff, or by the physicians and other health care professionals working with us.

How we may use and disclose health information about you

Our doctors, nurses, pharmacists, laboratory technicians, and other health care professionals may use health information about you to provide you with health care treatment or services. We may also disclose health information about you to others who are involved in taking care of you. For example, we may send health information about you to a physician specialist as part of a referral. Or, we may share information with a local nursing home in order to continue your care.

We may use and disclose health information about you to obtain payment for the treatment and services you receive from us or from the doctors and other health care professionals that treat you at the hospital. For example, we may send billing information to your insurance company or Medicare.

We may use and disclose health information about you to support our health care operations. For example, we may use health information to review the treatment and services we provide to you and to evaluate the performance of our staff in caring for you. You may also receive a telephone call asking if you were satisfied with the care you received.

Unless you object, we may disclose information to a family member or other person responsible for your care about your condition, status, and location.

Unless you tell us otherwise, we will include your name, location in the hospital, your general condition (good, fair, etc.), and religious affiliation in our patient directory and make this information available to anyone who asks for you by name. Unless you object, we may disclose this information to a member of the clergy.

We may use and disclose health information to contact you for an appointment reminder, to tell you about health-related services or to recommend possible treatment options or alternatives that may be of interest to you. We may contact you about supporting our fund raising efforts.

Subject to certain requirements, we may use or disclose health information about you without your prior authorization for other reasons:

We may give out health information about you for public health purposes; to report abuse or neglect; for health oversight reviews; in research studies, so long as provision is made for the protection of your health information; to medical examiners; for funeral arrangements and organ donation; in response to special law enforcement requests, valid judicial or administrative orders, or for authorized national security and intelligence activities; for workers' compensation purposes; to avert a serious threat to your health or safety or those of the public or another person; and when required by law (for example, state law requires certain reports to cancer registries). If you are or were a member of the armed forces, we may release information about you as required by military command authorities or the Department of Veterans Affairs. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. We must also release your health information when required by the Department of Health and Human Services to investigate our compliance with the privacy laws.

Your health information is protected by both federal and state laws. In situations where both laws apply, we will comply with the law that is most protective of your health information and/or gives you additional rights.

For any other purpose not covered by this Notice, we will ask for your written authorization before using or disclosing your health information. You may revoke this authorization at any time by notifying us in writing, except to the extent we have taken an action in reliance on your authorization.

Your rights regarding health information about you

You have the right to request in writing that you inspect and obtain a copy of the health information we maintain. We may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. In certain circumstances, we may deny your request. You may request that this denial be reviewed.

If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend your health information. The request must be in writing, and should state the reason for the amendment and the specific information to be amended.

You have the right to make a written request for a list of disclosures we have made of your health information. This list will not include disclosures made for treatment, payment, and health care operations, to your family, or those disclosures you authorized.

You have the right to request a restriction on the health information we use or disclose about you, including a right to request restrictions on disclosures to family members or friends. You must submit this request in writing. We are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, or we are otherwise required by law to make a disclosure.

You have the right to request that confidential communications with you be made in an alternative manner or location. This request must be in writing, but you do not need to state the reason for your request. For example, you may ask us to send information to your work address instead of your home address, or in a blank envelope with no distinguishing marks. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Written Requests

All written requests should be submitted to Ingrid Flemming at Northern Michigan Regional Hospital, 416 Connable Avenue, Petoskey, Michigan 49770.

Copies of Notice Changes

You have the right to obtain a paper copy of this Notice at any time, upon request, even if you have agreed to accept this Notice electronically.

We reserve the right to change this Notice, and to make the changed Notice effective for health information we already have about you as well as any information we receive in the future. Upon your request, we will provide you with any revised Notice. A revised Notice will also be posted in waiting areas throughout our facilities.

Complaints

If you are concerned that your privacy rights may have been violated or you disagree with a decision we made about your health information, you may file a complaint with our Privacy Officer, Ingrid Flemming, at Northern Michigan Regional Hospital, 416 Connable Ave. Petoskey, Michigan 49770, 231.487.7956. You may also send a written complaint to the U.S. Department of Health and Human Services. Our Privacy Officer can provide the address.

Under no circumstances will we ever ask you to waive your rights under this notice or retaliate against you in any manner for filing a complaint.

Effective Date

This Notice was published and became effective on April 14, 2003.

N0010930.2

For more information regarding our Privacy Practices, please call Ingrid Flemming at 231.487.7956.