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.

You will be asked if you have received a copy of the current privacy notice each time you are registered for an inpatient or outpatient service at McKenzie Memorial Hospital.  McKenzie Memorial Hospital uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.  We understand that medical information about you and your health is personal.  We are committed to protecting medical information about you.  This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor.  Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic. This notice will tell you about the ways in which we may use and disclose medical information about you, describe your rights and certain obligations we have regarding the use and disclosure of medical information.  We are required by law to:

• Make sure that medical information that identifies you (called Protected Health Information or PHI) is kept private;
• Give you this notice of our legal duties and privacy practices with respect to medical information about you;
• Explain your rights with regard to your medical information; and
• Follow the terms of the notice that is currently in effect.

We reserve the right to change the terms of this notice and our privacy practices at any time as allowed by law.  Any changes will apply to the PHI we already have.  Before we make any important change to our practices, we will promptly change this notice and post a new notice in the main lobby and the outpatient lobby.  You can request a copy of this notice from the Hospital at any time and can view a copy of the notice on our web site at www.mckenziehospital.com.

How McKenzie Memorial Hospital may Use or Disclose Your Health Information:

A. For Treatment:  We may disclose your PHI to physicians, nurses, medical students, and other healthcare personnel who provide you with health care treatment or services.  For example, if you’re being treated for a knee injury, we may disclose PHI to the physical rehabilitation department in order to coordinate your care.

B. To obtain Payment for Treatment:  We may use and disclose your PHI so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company, or a third party.  For example, we may give your health plan information about surgery you have received, or are going to receive at the hospital in an effort to be reimbursed for the surgery.  We may also contact your health plan for prior treatment authorizations and referrals.

C. For Health Care Operations:  We may use your PHI for purposes necessary for the daily operation of the hospital and to ensure that our patients receive the highest quality of care.  For example, we may use your PHI in order to evaluate the quality of healthcare services that you received or to evaluate the performance of the health care professionals who provided your care or services.  We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure we’re complying with the laws that affect us.

D. Appointment reminders and health-related benefits or services: We may use your PHI to provide reminders or information about treatment alternatives or health-related benefits and services that may be of interest to you.

E. Hospital Directories:  We may include certain limited information about you in the hospital directory while you are a patient here.  For example, we may provide your name, location in the facility, general condition, and religious affiliation for use by clergy and visitors who ask for you by name.  You may request not to be included in the hospital directory (known as anonymity).  If you request anonymity, it is your responsibility to notify family members or clergy of your hospital stay.  No hospital employee will acknowledge that you are a patient at the hospital, nor will any cards, flowers, etc. be sent to your room.  If you are incapacitated as the result of an emergency situation and you are unable to verbalize your desire to be included or to “opt” out of the hospital directory, hospital staff will decide, and based on the best interest of the patient will generally use and disclose information until the patient or next of kin can choose whether to opt out of the hospital directory.

F. Individuals Involved in Your Care or Payment for Your Care:   Based on your informal permission, we may release information about you to a friend or family member who is involved in your medical care or helps pay for your health care.  For example, we may provide general information on your condition to neighbor who you identify as someone who visits you daily to check on your well being and drives to the doctor when you need to go.

G. Fundraising and Marketing Activities:  We may use PHI to raise funds for our organization.  The money raised through these activities is used to expand and support the healthcare services and educational programs we provide to the community.  For example, we may notify you of hospital related services, products, or events.  We will not disclose your health information to an outside party without your prior authorization.

H. For Research purposes:  Under certain circumstances, we may use and disclose PHI about you for research purposes when an Institutional Review Board or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.  For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.

Special Situations in which McKenzie Memorial Hospital may use or disclose your health information:

A. Organ and Tissue Donation:  As a Medicare Condition of Participation, McKenzie Memorial Hospital is required by law to release health information about all deceased persons as necessary to facilitate organ or tissue donation to an organ procurement organization.  For example, if organ donation is an option, an organ procurement organization, like the Gift of Life or Michigan Eye Bank, may contact your next of kin to arrange for organ or tissue donation.

B. To Avoid a Serious Threat to Health and Safety:  In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.  For example, a circumstance in which a threat to public safety has been made and is reasonably thought to be valid.

C. As Required by Law:  We may use and disclose information about you as required by law.  For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot and other wounds or assaults; or when ordered in a judicial or administrative proceeding.  Patient authorization is not required when submitting health information as mandated by law.

D. National Security and Intelligence Activities:  We may release information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.  For example, if the President of the United States was visiting Sandusky, Michigan, we would be required to give Secret Service agents access to patient records, as needed, for purposes of ensuring the President’s safety.

E. Military and Veterans:  If you are a member of the armed forces, we may release PHI about you as required by military command authorities.  We may also release medical information about foreign military personnel to the appropriate foreign military authority.  For example, the Billing Department may call a military health plan to determine medical necessity, and obtain authorization for treatment.

F. For purposes of Public Health:  We may disclose your PHI to legal authorities for public health activities to prevent or control disease, injury, or disability.  We also provide coroners, medical examiners, and funeral directors necessary information relating to an individual’s death.

G. For Health Oversight activities:  We may disclose PHI to a health oversight agency for activities authorized by law.  For example, information required for audits, investigations, inspections, and licensure necessary for the government to monitor our compliance with government programs.

H. Workers’ Compensation:  We may disclose your PHI as authorized to the extent necessary to comply with worker’s compensation laws.  For example, if your employer’s worker’s compensation insurance carrier requests your medical information, we would provide the specific information requested as required by law.

I. Third Parties and/or Business Associates:  We may disclose your PHI to third parties with whom we contract to perform services on our behalf and with whom we have an agreement in place to ensure your information will be protected.  For example, the Michigan Health and Hospital Association (MHA) may request hospitals to submit health information in an effort to study health trends across the state.

J. Inmates:  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official when it is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; (3) for the safety and security of the correctional institution.

Other uses and disclosures of medical information not covered by this notice, or the laws that apply to legal issues will be made only with your written authorization and my be revoked at any time, unless we have already acted in reliance upon it. 

If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.

Your Rights Regarding Medical Information About You.

A. Right to Inspect and Copy:  You have the right to inspect and copy your protected health information that is part of the designated record set.  Usually, this includes medical and billing records, but does not include psychotherapy notes.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Please contact the HIM department at 810-648-6158 if you have any questions about access to your medical record.

B. Right to Request Amendments:  If you feel that the health information in your medical record is incorrect or incomplete, you may ask us to amend this information.  To request an amendment, you must obtain an Amendment Request form from the HIM Department; provide in writing the reasons for your request.  We may deny your request if it is not in writing or:

1. Was not created by this hospital, unless the person or entity that          created the information is no longer available to make the          amendment.

2. Is not part of the medical information kept by or for McKenzie    Memorial Hospital.

3. Is not part of the information which you would be permitted to inspect   and copy.

4. Is accurate and/or complete.

C. Right to Request a Restriction on Uses & Disclosures of Your PHI:  You have the right to ask that we limit how we use and disclose your PHI.  We will consider your request but are not legally required to accept it.  Your request must state, in writing, what restriction is requested and to whom you want the restrictions applied.  For example, you may request that we not disclose health information to your spouse, because you are separated; or ask us to restrict information from your private insurance carrier because you are going to assume financial responsibility for services received.  If professional judgment determines that it is not in your best interest to restrict use and disclosure of health care information about you, the request will be denied.  If we do agree to the requested restriction, we will make reasonable efforts to comply with your request unless the information is needed for emergency treatment.  You must make your written request for restriction to the Privacy Officer or Compliance Officer.

D. Right to Request to Receive an Accounting of Disclosures:  You may request in writing to receive an accounting of disclosures made about your health information to others for purposes other than treatment, payment, healthcare operations, or disclosures made with your authorization.  You must submit your written request to the Privacy Officer or Compliance Officer.  The request must state a time period which may not be longer than 6 years and may not include dates before April 14, 2003.  The first list you request within a 12-month period will be free; for additional lists, we will charge you for the cost of providing the list.  We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

E. Right to Request to Receive Confidential Communications:  You have the right to request that we communicate with you about medical matters in a certain format or at a certain location.  For example, you may request that we contact you at work rather than at home or by mailing health information to an alternate address.  We will make reasonable efforts to accommodate your request.  Your request must be in writing, submitted to the Privacy Officer or Compliance Officer and must specify how or where you wish to be contacted.

F. Right to Obtain a Paper Copy of this Notice:  You have the right to receive a paper copy of this notice.  We have copies available at our Registration sites, or you may request a copy from our Privacy Officer or Compliance Officer.  A copy of the Privacy Notice is also available at our website at www.mckenziehospital.com.

If you believe your privacy rights have been violated, you may file a complaint with the hospital, or with the Secretary of Health and Human Services without fear of retaliation. 

To file a complaint with McKenzie Memorial Hospital, send a detailed, written notification to the Compliance Officer at:

McKenzie Memorial Hospital
ATTN:  Compliance Officer
120 Delaware Street
Sandusky, MI 48471
(810) 648-6146

To file a complaint with the Secretary of Health and Human Services, send a detailed, written notification to:

U.S. Dept. of Health & Human Services
ATTN:  Office of the Secretary
200 Independence Ave. S. W.
Washington, D.C. 20201
(877) 696-6775

Effective date of this notice is September 2006.