MERCY HOSPITAL GRAYLING
NOTICE OF PRIVACY PRACTICES

Effective Date: 4/9/2003

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.

We at Mercy Hospital Grayling are a member of Trinity Health. Trinity Health is 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 will only use or disclose your PHI as permitted or required by applicable state law. Federal and state laws further restrict the uses and disclosures of your mental health, substance abuse, and infectious disease information. This notice applies to your individually identifiable health information in our possession including the medical records generated by us.

Mercy Hospital Grayling 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 Mercy Hospital Grayling and their medical staff in the main hospital, outpatient departments and clinics, including Mercy Manor. This Notice also applies to the utilization review and quality assessment activities of Munson Healthcare and Mercy Hospital Grayling as a strategic partner of Munson Healthcare.

I. Permitted Use or Disclosure

A. Treatment: Mercy Hospital Grayling will use and disclose your PHI in the provision and coordination of health care to carry out treatment functions.

Mercy Hospital Grayling will disclose all or any portion of your patient medical record information to your attending physician, consulting physician(s), nurses, pharmacists, technicians, medical students, dieticians, spiritual/ethical care providers, and other health care providers who have a legitimate need for such information in your care and continued treatment.

Different departments will share medical information about you in order to coordinate specific services, such as lab work, x-rays and prescriptions.

Mercy Hospital Grayling also will disclose your medical information to people or entities outside Mercy Hospital Grayling who will be involved in your medical care after you leave Mercy Hospital Grayling, such as other care providers and family who will provide services that are part of your care.

Mercy Hospital Grayling 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.

Mercy Hospital Grayling will use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.

Mercy Hospital Grayling will use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at Mercy Hospital Grayling.

If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Mercy Hospital Grayling will disclose your PHI to the correctional institution or law enforcement official.

B. Payment: Mercy Hospital Grayling 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 medical information may also be released to independent health care providers who were involved in your treatment (for example, Emergency Room physicians and Radiologists who are not employed by Mercy Hospital Grayling) or emergency delivery (via ambulance service) to Mercy Hospital Grayling so that they may seek payment for caring for you.

Mercy Hospital Grayling will disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.

C. Health Care Operations: Mercy Hospital Grayling will use and disclose your PHI during routine health care operations including quality review, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of Mercy Hospital Grayling, and for educational purposes.

For instance, Mercy Hospital Grayling 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.

Mercy Hospital Grayling may also use and disclose your PHI to support the sale, transfer, or other corporate restructuring of Mercy Hospital Grayling's assets.

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: Mercy Hospital Grayling will use and may also disclose some of your PHI for certain fund raising activities. For example, Mercy Hospital Grayling will use your demographic information (e.g., name, address and other contact information, age, gender, and insurance status) and the dates Mercy Hospital Grayling 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. Mercy Hospital Grayling may disclose limited PHI to a company contracted to conduct fundraising for Mercy Hospital Grayling. This company will use your PHI only for the purposes of fundraising for Mercy Hospital Grayling. (If you wish to opt-out, you may do so by contacting the Privacy Official.)

Medical Research: Mercy Hospital Grayling 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: Mercy Hospital Grayling will 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. We may send you cards for relevant events such as the birth of your child. Mercy Hospital Grayling will also send you information based on your own health concerns. Mercy Hospital Grayling 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 and when under state law the records are more protected from disclosure than under HIPAA. Certain federal laws also are more stringent than HIPAA. Mercy Hospital Grayling 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 and the state law defines a minimum necessary standard for release of mental health information. Disclosure is permitted with consent and for treatment without consent but only in an emergency. Minors in Michigan have more rights to confidentiality and protection of certain information (reproductive health, behavioral health and substance abuse) than under HIPAA. State law requires facilities to adopt policies regarding release of information outside the facility. If the facility policy requires consent for release, then consent will be required. State law genetic and HIV testing and disclosure consents remain in place.

II. Permitted Use or Disclosure with an Opportunity for You to Agree or Object

A. Family/Friends: Mercy Hospital Grayling will disclose PHI about you to a friend or family member who is involved in your medical care. Mercy Hospital Grayling will also give information to someone who helps you pay for your care. In addition, Mercy Hospital Grayling 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. Facility Directory: Mercy Hospital Grayling will list certain limited information about you in its Facility Directory if you are a hospital patient at Mercy Hospital Grayling. This information will include your name, location in Mercy Hospital Grayling, and your general condition (e.g., fair, stable, critical, etc.). This directory information will also be disclosed to people who ask for you by name, including your family members, friends, or other visitors. You have the right to request that your name not be included in Facility Directory. If you request to opt out of the Facility Directory, we cannot inform visitors of your presence, location, or general condition.

C. Spiritual Care: A hospital spiritual care provider may consult you as part of the healthcare team, or you may request a visit from a spiritual care provider by speaking to your nurse.

With your permission, Directory information including your name, location in Mercy Hospital Grayling, general condition, and religious affiliation will be given to a member of the community clergy from your denomination, such as a minister, priest or rabbi, even if they don't ask for you by name. You have a right to request that your name not be given to any community member of the clergy.

D. Promotional Communications: Mercy Hospital Grayling 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. Mercy Hospital Grayling does maintain a database of individuals for promotional communications, disease management, health promotion, and fundraising purposes. This database includes individuals to whom Mercy Hospital Grayling may have sent health improvement materials and news about Mercy Hospital Grayling previously and also individuals who have donated to Mercy Hospital Grayling or who have expressed an interest in donating to Mercy Hospital Grayling or other health-related activities. You may be included in this database. Mercy Hospital Grayling sends information to the individuals in this database about the programs and services of Mercy Hospital Grayling. If you wish to be deleted from this database, you may notify the Privacy Official of Mercy Hospital Grayling.

E. Media Conditions Reports: Mercy Hospital Grayling 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: Mercy Hospital Grayling is not permitted to provide your PHI to any other person or company for marketing to you of any products or services other than Mercy Hospital Grayling's products or services unless you have signed an authorization.

B. Research: Mercy Hospital Grayling 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, Mercy Hospital Grayling 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, except to the extent that Mercy Hospital Grayling has taken action in reliance on the authorization.

IV. Use or Disclosure Permitted by Public Policy or Law without your Authorization

A. Law Enforcement Purposes: Mercy Hospital Grayling 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 possible criminal conduct as part of a criminal investigation.

Required by Law: Mercy Hospital Grayling will disclose PHI about you when required by federal, state or local law to make reports or other disclosures. Mercy Hospital Grayling also will make disclosures for judicial and administrative proceedings such as lawsuits or other disputes in response to a court order or subpoena. Mercy Hospital Grayling will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violence. Mercy Hospital Grayling 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. Mercy Hospital Grayling will make certain disclosures that are required in order to comply with workers' compensation or similar programs.

B. Coroners, Medical Examiners, Funeral Directors: Mercy Hospital Grayling 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. Mercy Hospital Grayling will also disclose your medical information to funeral directors as necessary to carry out their duties.

C. Organ Procurement: Mercy Hospital Grayling will disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes when donation has been authorized or to verify that appropriate organ procurement procedures were followed.

D. Health or Safety: Following the requirements of the Michigan Department of Commerce, Mercy Hospital Grayling will use and disclose PHI to avert a serious threat to health and safety of a person or the public. Mercy Hospital Grayling will use and disclose PHI to Public Health Agencies for immunizations, communicable diseases, etc. Mercy Hospital Grayling 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 we at Mercy Hospital Grayling must maintain all records concerning your hospitalization and treatment by Mercy Hospital Grayling, 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 have a copy made of your PHI as long as we maintain it except for: psychotherapy notes, information that may be used in anticipation of, or that will be used in a civil, criminal or administrative action or proceeding, and where prohibited or protected by law. Mercy Hospital Grayling 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 Mercy Hospital Grayling 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;
  
• Mercy Hospital Grayling 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, Mercy Hospital Grayling will allow the review of its decision by a health care professional that Mercy Hospital Grayling 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 Mercy Hospital Grayling's Health Information Services Department. Mercy Hospital Grayling will respond to your request within 30 days of its receipt. If Mercy Hospital Grayling cannot, Mercy Hospital Grayling will notify you in writing to explain the delay and the date by which we will act on your request. In any event, Mercy Hospital Grayling 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 Mercy Hospital Grayling maintains it. However, Mercy Hospital Grayling will deny your request for amendment if:

• Mercy Hospital Grayling 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 Mercy Hospital Grayling denies your request for changes in your PHI, Mercy Hospital Grayling will notify you in writing with the reason for the denial. Mercy Hospital Grayling will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that Mercy Hospital Grayling include your request for amendment and the denial any time that Mercy Hospital Grayling discloses the information that you wanted changed. Mercy Hospital Grayling 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 Mercy Hospital Grayling's Health Information Services Department, including your reason to support the requested amendment. Mercy Hospital Grayling will respond to your request within 60 days of its receipt. If Mercy Hospital Grayling cannot, Mercy Hospital Grayling will notify you in writing to explain the delay and the date by which Mercy Hospital Grayling will act on your request. In any event, Mercy Hospital Grayling 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 Mercy Hospital Grayling 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 in custodial situations; 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 Mercy Hospital Grayling's Health Information Services Department. You must include the time period of the accounting, which may not be longer than 6 years. Mercy Hospital Grayling will respond to your request within 60 days from its receipt. If Mercy Hospital Grayling cannot, Mercy Hospital Grayling will notify you in writing to explain the delay and the date by which Mercy Hospital Grayling will act on your request. In any event, Mercy Hospital Grayling will act on your request within 90 days of its receipt.

In any given 12-month period, Mercy Hospital Grayling 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 name not be used in the waiting room or that information about your expected discharge date not be shared with your family. Mercy Hospital Grayling will consider your request but is not required to agree to the requested restrictions.

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 Mercy Hospital Grayling only contact you at work or by mail. We will make every attempt to honor your request, but we reserve the right to deny unreasonable requests.

F. Right to Opt Out of the Facility Directory: You have the right to ask that your name not be included in the Facility Directory. If you request to opt out of the Directory, Mercy Hospital Grayling cannot inform visitors and callers of your presence, location, or general condition.

G. 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 Mercy Hospital Grayling or with the Secretary of the Department of Health and Human Services. To file a complaint with Mercy Hospital Grayling, please contact Mercy Hospital Grayling's Director of Customer's Relations/Quality Management at:

1100 East Michigan Avenue
Grayling, MI 49738
(989) 348-0401 or
The Alert Line at 1-866-477-4661

All complaints must be submitted in writing directly to Mercy Hospital Grayling's Customer Relations Manager. Mercy Hospital Grayling assures 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 Mercy Hospital Grayling's mission to improve the health of the community, Mercy Hospital Grayling will share your PHI with other organizations as described below who have agreed to abide by the terms described below:

A. Medical Staff: The medical staff and Mercy Hospital Grayling participate together in an organized health care arrangement to deliver health care to you. Mercy Hospital Grayling and its medical staff 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 Mercy Hospital Grayling. Physicians and allied health care providers are members of Mercy Hospital Grayling's medical staff and will have access to and use your PHI for treatment, payment and health care operations purposes related to your care within Mercy Hospital Grayling. Mercy Hospital Grayling will disclose your PHI to the medical staff for payment, treatment and health care operations.

B. Business Associates: Mercy Hospital Grayling will use and disclose your PHI to business associates contracted to perform business functions on its behalf including Munson Healthcare, who performs certain business functions for Mercy Hospital Grayling.
Whenever an arrangement between Mercy Hospital Grayling 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 Munson Healthcare: Mercy Hospital Grayling, members of Munson Healthcare and Munson Healthcare 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 Munson Healthcare and its members. Members of Munson Healthcare will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or healthcare operations. As a strategic partner of Munson Healthcare, Mercy Hospital Grayling and other hospitals, nursing homes, and health care providers in Munson Healthcare share your PHI for utilization review and quality assessment activities of Munson Healthcare and its members. Members of Munson Healthcare also use your PHI for your treatment, payment to Mercy Hospital Grayling and/or for the health care operations permitted by HIPAA with respect to our mutual patients.

VIII. Additional Information

For further information regarding the subjects covered in this Notice of Privacy Practices, please contact Mercy Hospital Grayling's Privacy Official at (989) 348-0573.

IX. Changes to this Notice

Mercy Hospital Grayling will abide by the terms of the Notice currently in effect. Mercy Hospital Grayling reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. Mercy Hospital Grayling will provide you with the revised Notice at your first visit following the revision of the Notice.

If you are a Mercy Hospital Grayling patient and have a compliment, concern, or complaint, please contact one of our Patient Liaisons.

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