HIPAA Privacy Notice

Brookhaven Medical Care Facility
1890 Apple Avenue
Muskegon, Michigan 49442
Phone 231 724 3500/Fax 231 724 3571

Privacy Notice

NOTICE OF HEALTH INFORMATION PRACTICES

THIS NOTICE DESCRIBEDS HOW MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

THIS NOTICE IS INTENDED TO PROVIDE AN OVERVIEW OF YOUR RIGHTS UNDER HIPAA WITH RESPECT TO THE USE AND DISCLOSURE OF THE INFORMATION THAT YOU PROVIDE TO BROOKHAVEN MEDICAL CARE FACILITY.

PLEASE REVIEW IT CAREFULLY AND CONTACT THE FACILITY PRIVACY OFFICER WITH ANY QUESTIONS OR CONCERNS YOU MAY HAVE.

This notice of privacy practices describes how we may use and disclose protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to accessing control of your protected health information that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this privacy notice. The Facility may change the terms of its notice at any time. The new notice will be effective for all protected health information that we maintain at that time. You may also obtain a copy by contacting the Facility's Privacy Officer and requesting that the Facility give you a copy for your review

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

You will be asked by the Facility to acknowledge receipt of this document. By acknowledging this notice, the disclosure of your protected health information for treatment, payment, and health care operations can take place only as outlined in the notice. The Facility will use or disclose your protected health information as described in this Notice. Your protected health information may be used or disclosed by the Facility - and others outside or others involved in your care and treatment for purposes of providing health care services to you. Your protected health

information may also be used and disclosed to pay your health care bills and support the operation of this Facility.

The following are examples of the types of uses and disclosures of your protected health care information that the Facility is permitted to make, once you sign the consent form. These examples are not meant to be exhaustive, but only describe the type of uses and disclosures.

o Treatment

The Facility will use and disclose protected health information to provide, coordinate and manage your health care and any related services provided by the Facility. This will include the coordination management of your health care with third parties who may need to have access to protected health information. For example, the Facility will disclose protected health information, as necessary to any therapists who work with the Facility and who may provide care for you. We will also disclose protected health information to physicians who may be treating you at the Facility, so they have access to the information to provide care for you. We may also disclose protected health information to specialists or laboratories who may become involved in your care.

o Payment

Protected health information will be used as needed to obtain payment for health-care services. This may include activities by your health insurance plans which they may need to undertake prior to approval of services, to recommend course of care, make determinations of eligibility for coverage for insurance group benefits, and for determination of whether services are medically necessary.

o Health Care Operations

The Facility may use or disclose, as needed your protected health information in order to support the business activities of the Facility. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical or nursing students, training of nurse aides, licensing, and conducting or arranging for other business activities.

Notice of Health Information Practices

The Facility will share protected health information with third party business associates to perform various activities for the facility. For example, information concerning your care at the Facility may be disclosed to accountants, consultants, and other parties involved in the auditing

and review of our Facility for purposes of reimbursement for your care. The Facility is also required by law to provide access to information to the state and federal government for purposes of Medicare and Medicaid survey and certification.

The Facility may also use or disclose protected health information as necessary to provide you with information about treatment alternatives or other health related benefits and services that might be of interest to you. For example, your name may be used to send you information about the Facility's activities, your photograph along with information concerning your birth date, may be included in Facility wide newsletters or for other recognition at the Facility's discretion and/or may be posted outside of your room.

The Facility may also use or disclose protected health information as necessary in order to provide you with information about fundraising activities, which are supported by the Facility. If you do not want to receive these materials, please contact our Privacy Officer and request that these materials not be sent to you.

o Other Permitted Required Uses and Disclosures

The Facility may use and disclose protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, the Facility will use its professional judgment to make those disclosures, which it deems to be in your best interest.

o Facility Resident Directory/Family/Clergy

Unless you object, the Facility will use and disclose your name in the Facility directory and Facility newsletter. Your general condition may be disclosed to Facility members and your religious affiliation to members of the clergy. Visitors who request it may receive your room number for purposes of facilitating a visit.

o Others involved in Health-Care

Unless you object, the Facility may disclose to a member of your legal surrogate, family, relative, close friend or any other person you identify protected health information that directly relates to that persons involvement in your health care. If you are unable to agree or object to such a disclosure, the Facility may disclose such information as it deems necessary for your best interest, based upon it's professional judgment. The Facility may use or disclose protected health information to notify and/or communicate with family members, personal representatives or other person(s) who are responsible for your care.

Notice of Health Information Practices

o Emergencies

The Facility may disclose or use your protected health information in emergency treatment situations. If this happens, the Facility will try to obtain your consent as soon as reasonably practical after delivery of treatment or care. If the Facility is required by law to treat you and has attempted to obtain your consent but is unable to do so, it will use it's professional judgment to disclose that protected health information, which it determines is reasonably necessary to provide for your care and treatment.

o Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke this authorization at any time in writing, except to the extent the Facility has taken action in reliance upon your authorization.

o Communication Barriers

The Facility may use and disclose protected health information if it believes it has attempted to obtain consent from you but is unable to do so due to substantial communication barriers and the Facility has determined, using professional judgment, that you intend the consent to use or disclosure under the circumstances.

OTHER PERMITTED AND REQUIRED USES THAT MAY BE MADE WITHOUT YOU CONSENT, AUTHORIZATION, OR OPPORTUNITY TO OBJECT.

o Disclosures Authorized by Law

The Facility may use or disclose protected health information following situations without your consent or authorization. These situations include:

1. Required by law . The Facility may use or disclose protected health information

to the extent that the use or disclosure is required by law. The use or disclosure

will be made in compliance with and limited to the extent required by law. You

will be notified as required by law of any such disclosures.

2. Public health . The Facility may disclose protected health information to public

health authorities that are permitted by law to collect and receive such

information. The Facility may also disclose protected health information, directed

by the public health authority, to a foreign government agency that is

collaborating with the public health authority.

Notice of Health Information Practices

3. Communicable disease . The Facility may disclose protected health information

as authorized by law to persons who may have been exposed to a communicable

disease or may otherwise be at risk of contracting or spreading the disease or

condition.

4. Health oversight . The Facility may disclose protected health information to a

health oversight agency for activities authorized by law, such as minimum data

set transmission, audits, investigations, and inspections. Oversight agencies

seeking this information include government agencies which oversee the

healthcare system, government benefit programs, and other government

regulatory programs.

5. Abuse or neglect. The Facility may disclosure protected health information to

public health authority who is authorized by law to receive reports of actual or

suspected abuse or neglect. The Facility may disclose protected health

information if there has been abuse and neglect or domestic violence to the

government agency or agencies authorized to receive such information. In those

cases, its disclosure will be consistent with the requirements applicable in federal

and state laws.

6. FDA. The Facility may disclose protected health information to a person or

entity, as required by the food or drug administration to report adverse events,

product defects or problems, to enable product recalls, etc., as required by law.

7. Legal proceeding . The Facility may disclose protected health information in the

course of any judicial or administrative proceeding, and in response to an order of

a court or administrative tribunal, in response to a subpoena or discovery requests

or other lawful process.

8. Law enforcement . The Facility may disclose protected health information for

law enforcement purposes. The law enforcement purposes include legal

processes and investigations, otherwise required by law; limited information

request for identification and location purposes; requests pertaining to victims of

crimes; suspicion that death has occurred as a result of criminal conduct; and

good faith belief that a crime has occurred on the premises of the Facility; and in

emergency situations not on the premises but where a crime is likely to occur.

9. Coroners, medical examiners, and funeral directors . The Facility may

disclose protected health information to coroners and medical examiners for

notification purposes, determining cause of death, or for other duties required by

law. The Facility may disclose protected health information to a funeral director

as required by law in order to permit the funeral directors to carry out their duties.

The Facility may disclose such information in reasonable anticipation of death.

Notice of Health Information Practices

Protected health information may be used and disclosed for organ donation

purposes.

10. Research . The Facility may disclosure protected health information to

researchers when the research has been approved by an institutional review board

which has reviewed the research proposal and has established protocols to ensure

the privacy of your protected health information.

11. Criminal activity . Consistent with applicable federal and state laws, the

Facility may disclose protected health information if it believes that the use or

disclosure is necessary to prevent or lessen the seriousness of an imminent threat

to health information if it is necessary for law enforcement authorities to identify

or apprehend an individual.

12. Military activity/national security . The Facility may use and disclose protected

health information of individuals who are armed forces personnel which are

deemed necessary by appropriate military authorities; for purposes of determination of eligibility for VA benefits; or to foreign military authorities of or protected health information to authorized federal officials for conducting national security activities.

13. Workers compensation . Your protected health information may be disclosed for

purposes of complying with Michigan Workers' Compensation laws.

o Rights to Restrict Disclosure

The following is a statement of your rights with respect to protected health information and a brief description of how you may exercise your rights.

You have the right to inspect or copy your protected health information. Under law, this means you have the right to inspect and to copy your protected health information, as it is contained in your designated record as long as the Facility maintains that protected health information. Designated records include the medical and billing records and other records that the Facility uses for making decisions about you.

Under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in anticipation of or use in a criminal or civil action or proceeding; protected information which is subject to any law which limits your access to protected information. In some circumstances you may have a right to have this decision reviewed. Please contact the Privacy Officer if you have questions about access to medical records.

You have the right to request a restriction on the disclosure or use of your protected health information. Under the law, this means you have the ability to ask the Facility to not disclose or use any part of your protected health information for purposes of treatment, payment or health

Notice of Health Information Practices

care operations. You may also request that no part of protected health information be disclosed to the family members or friends who may not be involved in your care and for whom the notification provisions of the law apply. You must be specific in your request as to which information you do not want disclosed and to whom the restriction will apply.

The Facility is not required to agree to the restriction that you request. If the Facility believes it is not in your best interest to limit the disclosure of your protected health information or disagrees with your request, your protected health information will not be restricted. If the Facility does agree with the requested restriction, the Facility will not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction request with the Facility's Privacy Officer.

o Amendments of Records

You have the right to receive any amendment to protected health information. You may not however amend your psychotherapy records.

The right to amend your records means you may request the protected health information about yourself in a designated record be modified and/or changed as long as the Facility maintains this information. In certain cases the Facility may deny your request for amendment. If the Facility denies your request for amendment, you have the right to file a statement of disagreement with the Facility. Please contact the Privacy Officer with any questions in this regard.

You have the right to have an accounting of any disclosures made by the Facility after April 14, 2003. Disclosures made for the purpose of treatment, payment and healthcare operations are not required to be kept in a log by the Facility.

o Complaints

You may complain to the Facility or the Secretary of Health and Human Services if you believe that your privacy rights have been violated by the Facility. Complaints should be filed with either the facility's Privacy Officer or Administrator. The Facility's Privacy Officer can be contacted at 231 315 2393 or in writing at 1890 Apple Avenue, Muskegon, MI , 49442. The Facility will not retaliate against any person who makes a complaint under this Policy.

The Notice was published by the Facility on

and became effective on April 14, 2003