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Effective Date: April 14, 2003


Saint Joseph Mercy Health System (referred to as SJMHS throughout the rest of this document) understands that your health information is highly personal, and we are committed to safeguarding your privacy. SJMHS is required by law to maintain the privacy of individually identifiable patient health information (this information is “protected health information” and is referred to as “PHI” throughout the rest of this document). PHI includes identifiable information about your health care and payment for that health care. 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.

This Notice applies to the delivery of health care by SJMHS and its medical staff in our hospitals, outpatient departments, clinics, home care and hospice programs, system-owned physician practices, and pharmacies. This Notice also applies to the utilization review and quality assessment activities of Trinity Health and SJMHS as a member of Trinity Health.

I. Permitted Use or Disclosure

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

  • SJMHS will 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.
  • SJMHS will disclose your medical information to people or entities outside SJMHS who will be involved in your medical care after you leave SJMHS, such as family members, friends, community clergy and others who will provide services that are part of your care.
  • SJMHS 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.
  • SJMHS will use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.
  • SJMHS will use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at SJMHS.
  • If you are an inmate of a correctional institution or under the custody of a law enforcement officer, SJMHS will disclose your PHI to the correctional institution or law enforcement official.
B. Payment: SJMHS 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.
  • SJMHS will disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.
C. Health Care Operations: SJMHS will use and disclose your PHI for health care operations purposes. The following are examples of how SJMHS will use and/or disclose your PHI:
  • For case management, quality assurance, utilization review, accounting, auditing, population based activities relating to improving health or reducing health care costs, education, accreditation, licensing and credentialing activities of SJMHS.
  • Disclose it to consultants, accountants, auditors, attorneys, transcription companies, information technology providers, and other business associates that perform services for SJMHS.
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: SJMHS maintains a database of information to contact individuals for fund-raising initiatives designed to expand and improve the services and programs we provide to the community. The information may include things such as your demographic information, treating physician and service, and dates of service. SJMHS may disclose limited PHI from this database to a company contracted to conduct fundraising for SJMHS. This company will use your PHI only for the purposes of fundraising for SJMHS. Any fundraising communication sent to you will let you know how you can exercise your right to opt-out of receiving similar communications in the future.
  • Health Care Research: SJMHS may disclose your PHI without your Authorization to health care researchers who request it for approved health care research projects. Researchers are required to safeguard the PHI they receive.
  • Information and Health Promotion Activities: SJMHS 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 specific information based on your own health concerns.

E. More Stringent State and Federal Laws:
The State law of Michigan is more stringent than HIPAA in several areas. Certain federal laws also are more stringent than HIPAA. SJMHS will continue to abide by these more stringent state and federal laws.

  • More Stringent 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.
  • More Stringent State Laws: State law is more stringent when the individual is entitled to greater access to records than under HIPAA. State law also is more restrictive when the records are more protected from disclosure by state law than under HIPAA. In cases where SJMHS provides treatment to a patient who resides in a neighboring state, SJMHS will abide by the more stringent applicable state law. All of Michigan’s state laws regarding its consent requirements continue to apply. Patients in Michigan have more rights of access to mental health information. Michigan law also defines a minimum necessary standard for release of mental health information. HIPAA permits us to disclose PHI as permitted by state law. Michigan law allows the disclosure of PHI to state agencies regarding certain medical conditions such as cancer, communicable diseases, and HIV/AIDS.

F. Health Information Exchange:
SJMHS shares your health records electronically with Michigan Health Connect (MHC) for the purpose of improving the overall quality of health care services provided to you (e.g., avoiding unnecessary duplicate testing). The electronic health records will include sensitive diagnosis such as HIV/AIDS, sexually transmitted diseases, genetic information, and mental health substance abuse, etc. The HIE is functioning as our business associate and, in acting on our behalf, the HIE will transmit, maintain and store your PHI for treatment, payment and health care operation purposes. The HIE has a duty to implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of your medical information. You have the right to “opt-out” and prevent your health information from being seen or used by MHC by completing and submitting a non-participation form to MHC by mail, fax or website. You may contact MHC to obtain a non-participation form or if you have any questions or concerns: Michigan Health Connect, 4829 East Beltline, Suite 303, Grand Rapids, MI 49525. Phone: (877) 269-7860

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

A. Family/Friends: SJMHS will disclose PHI about you to a friend or family member who is involved in your medical care. You have a right to request that your PHI not be shared with some or all of your family or friends. In addition, SJMHS 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.

B. Facility Directory: SJMHS will include certain information about you in the Facility Directory while you are a hospital patient. This information will include your name, location in SJMHS, your general condition (“good,” “fair,” “serious,” or “critical”) and your religious and/or congregational affiliation. The directory information, except for your religious and/or congregational affiliation, will be disclosed to people who ask for you by name. You have the right to request that your name not be included in the Facility Directory. If you request to opt out of the Facility Directory, we cannot inform visitors or callers of your presence, location, or general condition.

C. Spiritual Care: Directory information, including your religious affiliation, will be given to a member of the clergy, such as pastor, priest, rabbi, or imam, even if they do not ask for you by name. Spiritual care providers are members of the health care team at SJMHS and may be consulted upon regarding your care. You have the right to request that your name not be given to any member of the clergy.

D. Media Reports: SJMHS will release Facility Directory information to the media (excluding religious affiliation) if the media requests information about you using your name and after we have given you an opportunity to agree or object.

III. Use or Disclosure Requiring Your Authorization

A. Marketing: Subject to certain limited exceptions, your written authorization is required in cases where SJMHS receives any direct or indirect financial remuneration in exchange for making the communication to you which encourages you to purchase a product or service or for a disclosure to a third party who wants to market their products or services to you.

B. Research: For many types of research, SJMHS will be required to obtain your authorization before allowing the researchers to use or disclose your PHI.

C. Psychotherapy Notes: Most uses and disclosures of psychotherapy notes require your written authorization.

D. Sale of PHI: Subject to certain limited exceptions, disclosures that constitute a sale of PHI requires your written authorization.

E. Other Uses and Disclosures: Any other uses or disclosures of PHI that are not described in this Notice of Privacy Practices require 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: SJMHS will disclose your PHI for law enforcement purposes as required by law, such as identifying a criminal suspect or a missing person, or providing information about a crime victim or criminal conduct.

B. Required by Law: SJMHS will disclose PHI about you when required by federal, state or local law. Examples include disclosures in response to a court order / subpoena, mandatory state reporting (e.g., gunshot wounds, victims of child abuse or neglect), or information necessary to comply with other laws such as workers’ compensation or similar laws. SJMHS will report drug diversion and information related to fraudulent prescription activity to law enforcement and regulatory agencies.

C. Public Health or Safety: SJMHS will use and disclose PHI to avert a serious threat to health and safety of a person or the public. SJMHS will disclose PHI to state investigators regarding quality of care or to Public Health Agencies for immunizations, communicable diseases, etc. SJMHS 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.

D. Coroners, Medical Examiners, Funeral Directors: SJMHS 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. SJMHS will also disclose your medical information to funeral directors as necessary to carry out their duties.

E. Organ Procurement: SJMHS will disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes.

F. Specialized Government Functions: SJMHS will disclose your PHI regarding government functions such as military, national security and intelligence activities. SJMHS will use or disclose PHI to the Department of Veterans Affairs to determine where you are eligible for certain benefits.

G. Immunizations: SJMHS will disclose proof of immunization to a school where the state or other similar law requires it prior to admitting a student.

V. Your Health Information Rights

You have the following rights concerning your PHI:

A. Right to Inspect and Copy: Subject to certain limited exceptions, you have the right to access your PHI and to inspect and copy your PHI as long as we maintain it. If SJMHS denies your request for access to your PHI, we will notify you in writing with the reason for the denial. For example, you do not have the right to psychotherapy notes or to inspect the information which is subject to law prohibiting access. You may have the right to have this decision reviewed.

You also have the right to request your PHI in electronic format in cases where SJMHS utilizes electronic health records. You may also access information via patient portal if made available by SJMHS.

You may be required to pay a reasonable copying fee for your request. You will be provided with information regarding fees when you make your request.

B. Right to Amend: You have the right to amend your PHI for as long as SJMHS maintains it. You must make your request for amendment of your PHI in writing to SJMHS, including your reason to support the requested amendment. However, SJMHS will deny your request for amendment if:

  • SJMHS 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
  • SJMHS has found the information to be accurate and complete.

If SJMHS denies your request to amend your PHI, SJMHS will notify you in writing with the reason for the denial. SJMHS will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that SJMHS include your request for amendment and the denial any time that SJMHS discloses the information that you wanted changed. SJMHS may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.

C. Right to an Accounting: You have a right to receive an accounting of the disclosures of your PHI that SJMHS made, except for the following disclosures:

  • To carry out treatment, payment or health care operations;
  • In response to an authorization signed by you
  • To you;
  • To persons involved in your care;
  • For national security or intelligence purposes;
  • To correctional institutions or law enforcement officials.

You must make your request for an accounting of disclosures of your PHI in writing to SJMHS. Forms are available by contacting the Health Information Management Department. You must include the time period of the accounting, which may not be longer than 6 years.

In any given 12-month period, SJMHS 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. SJMHS will consider your request, but is not required to agree to the requested restrictions.

E. Right to Request Restrictions to a Health Plan: You have the right to request a restriction on disclosure of your PHI to a health plan (for purposes of payment or health care operations) in cases where you paid out of pocket, in full, for the items received or services rendered.

F. 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 SJMHS only contact you at work or by mail. A request for a confidential communication must be made in writing. Request for Confidential Communications forms are available by contacting the Health Information Management Department.

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. Download a printable version of this document.

VI. Breach of Unsecured PHI

If a breach of unsecured PHI affecting you occurs, SJMHS is required to notify you of the breach.

VII. Complaints

If you believe your privacy rights have been violated, you may file a complaint with SJMHS or with the Secretary of the Department of Health and Human Services. Complaints may be submitted in writing or by calling the Patient Relations Department at 734-712-2700 or the Privacy Officer at 734-712-4542. For St. Mary Mercy Hospital related complaints, contact the Privacy Officer at 734-655-1409. SJMHS will acknowledge receipt of your complaint, either verbally or in writing, within a reasonable period of time. SJMHS assures you that there will be no retaliation for filing a complaint.

VIII. Sharing and joint use of your Health Information

In the course of providing care to you and in furtherance of the SJMHS’s mission to improve the health of the community, SJMHS 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 SJMHS participate together in an organized health care arrangement to deliver health care to you at SJMHS. Both SJMHS 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 SJMHS. Physicians and allied health care providers are members of SJMHS’s medical staff and will have access to and use of your PHI for treatment, payment and health care operations purposes related to your care within SJMHS. SJMHS will disclose your PHI to the medical staff for treatment, payment, and health care operations.

B. Membership in Trinity Health: SJMHS and members of 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. SJMHS and other 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 SJMHS and/or for the health care operations permitted by HIPAA with respect to our mutual patients. Please go to Trinity Health’s website for a listing of member organizations. Or, alternatively, you can call SJMHS’s Privacy Official to request the same.

C. Business Associates: SJMHS will disclose your PHI to business associates contracted and their contractors to perform business functions on its behalf including Trinity Health, its parent company who performs certain business functions for SJMHS.

IX. Additional Information

If you have any questions, concerns, or want further information regarding the issues covered by this Notice of Privacy Practice or seek additional information regarding SJMHS’s privacy policies and procedures, contact the following:

For Ann Arbor, Chelsea, Livingston and Saline, please contact:
Privacy Officer: 5301 East Huron River Drive, PO Box 995, Ann Arbor, MI 48106-0995. Telephone: 734-712-4542.

For St. Mary Mercy, please contact: Privacy Official, 36475 Five Mile Road, Livonia, MI 48154. Telephone: 734-655-1409.

IX. Changes to this Notice

SJMHS will abide by the terms of the Notice currently in effect. SJMHS reserves the right to make material changes to the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. SJMHS will provide you with the revised Notice at your first visit following the revision of the Notice in cases where it makes a material change in the Notice.