• Hackley Health System, including Hackley Hospital, Hackley Lakeshore Hospital, Hackley Primary Care Network, Hackley Sports Med & Rehabilitation, Hackley Physical Therapy Centers, Hackley Visiting Nurse and Hospice, Child and Family Services of Muskegon, Hackley Health Management, Hackley Healthcare Equipment, Hackley Pharmacies, Hackley Labs and Hackley Orthotics and Prostetics,
• Spectrum Health Hospitals, including DeVos Children’s Hospital, Butterworth Campus, Blodgett Campus, East Paris Surgery Center and South Pavilion
• Spectrum Health Urgent Care Centers, Spectrum Health Occupational Services, Spectrum Health Primary Care Partners, Spectrum Health Kent Community Campus, Spectrum Health Reed City Campus, Aero Med at Spectrum Health, Grand Rapids Clinical Oncology Program
• Spectrum Health Continuing Care Group, including Spectrum Health Continuing Care Center, Spectrum Health Worth Residential Services and Spectrum Health Worth Home Care
• Visiting Nurse Association of West Michigan, including Visiting Nurse Services and Visiting Nurse ExtraCare

In addition, the "Spectrum Health OHCA" (for "organized health care arrangement") will refer to the Spectrum Health facilities as well as those health care providers who, while not necessarily legally affiliated with Spectrum Health, may provide you with care or treatment at a Spectrum Health facility.
This Notice describes Spectrum Health facilities’ privacy practices and those of all described below (all of whom are part of the Spectrum Health OHCA) while providing services at a Spectrum facility:

• Any health care professional authorized to enter information into any medical record established and maintained by Spectrum Health.
• All departments and units of Spectrum Health hospitals, clinics, and offices.
• All employees, staff, volunteers and other Spectrum Health personnel.
• The Medical Staff of any Spectrum Health facility and the individual members of such a Medical Staff.
• Any other health care provider who, although not employed by a Spectrum Health facility, provides services to you at a Spectrum Health facility, including but not limited to the following types of providers and their personnel: laboratory and diagnostic providers; pharmacies; and physicians and other health professionals, such as nurses, nurse practitioners, physician assistants, physical therapists.
  

• maintain the privacy of your medical information that identifies you;
• give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of the Notice that is currently in effect.
  

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to other health care providers who are involved in taking care of you or with whom we may consult or to whom we may refer you as part of your care as a Spectrum Health patient, including but not limited to: doctors, nurses, technicians, medical students, laboratory and diagnostic providers, pharmacies, and other health professionals, such as nurse practitioners, physician assistants, physical therapists or other personnel who provide treatment to you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different Spectrum Health departments also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, x-rays, therapy or to coordinate a referral. We also may disclose medical information about you to people outside Spectrum Health who may be involved in your medical care after hospital care, such as family members, or others we use to provide services that are part of your care. We also may disclose your medical information to another health care provider to whom or to which you are referred or transferred for health care services.
• For Payment. We may use and disclose medical information about you so that the treatment and services you receive at Spectrum Health may be billed to (and payment may be collected from) you, an insurance company or other third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. Some providers who render care at Spectrum Health bill separately from Spectrum Health and we may provide payment related information to them to coordinate the billing process. Another example of our use and disclosure of medical information about you is attempting to contact you in writing or via telephone for purposes of verifying insurance coverage or gaining more information regarding insurance coverage.
• For Health Care Operations. We may use and disclose medical information about you for Spectrum Health health care operations. These uses and disclosures are necessary to run Spectrum Health entities and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services Spectrum Health should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. In these cases, we will remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. We may also use certain medical and non-medical information to contact you to solicit your opinions on the quality of services you received from Spectrum Health and how Spectrum Health may improve its services.
• Incidental Uses and Disclosures. We may inadvertently use or disclose your medical information when such use or disclosure is incidental to another use or disclosure that is permitted or required by law. For example, while we have safeguards in place to protect against others overhearing our conversations that take place between doctors, nurses or other Spectrum Health personnel, there may be times that such conversations are in fact overheard. Please be assured, however, that we have appropriate safeguards in place to avoid such situations as much as possible.
• Appointment Reminders. We may use and disclose medical information to provide appointment reminders when you have scheduled treatment or medical service at a Spectrum Health facility.
• Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related services or benefits that may be of interest to you.
• Fund-raising Activities. We may use certain non-medical information (including but not limited to name, address, telephone number, dates of service, age, and gender) to contact you in the future to raise money for Spectrum Health affiliates through a foundation owned or controlled by Spectrum Health. The money raised will be used to expand and improve the services and programs we provide the community. If you do not wish to be contacted for fund-raising efforts, please notify the Chief Patient Privacy and Information Security Officer in writing.
• Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient at a Spectrum Health hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be disclosed to people who ask for you by name. In addition, the hospital may keep a specific directory listing your religious affiliation and disclose the directory to members of the clergy. This is so your family, friends and clergy can visit you in the hospital and know your general condition. You have a right to request a restriction on the use or disclosure of your information in hospital directories. To request restrictions, you must tell us during registration. You also have the right to object to the inclusion of your information in the directory.
• Individuals Involved in Your Care or Payment for Your Care. We may disclose medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who is involved with payment or helps pay for your care. We may also tell your family or friends your general condition. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
• Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. 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. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the Spectrum Health facility where it resides. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.
• As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law or regulation.
• To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
• Communications Regarding Spectrum Health's Programs or Products. We may use and disclose your health information to make a communication to you to describe a health-related product or service of Spectrum Health. In addition, we may use or disclose your health information to tell you about products or services related to your treatment, case management or care coordination, or alternative treatments, therapies, providers or settings of care for you. We may occasionally tell you about another company's products or services, but will use or disclose your health information for such communications only if they occur in person with you. We may also use and disclose your health information to give you a promotional gift from us that is a minimal value.

SPECIAL SITUATIONS

• Organ and Tissue Donation. If you are an organ donor, we may disclose medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
• Military and Veterans. If you are a member of the armed forces, we may disclose medical information about you as required by military command authorities. We may also disclose medical information about foreign military personnel to the appropriate foreign military authority.
• Workers' Compensation. We may disclose medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
  • to prevent or control disease, injury or disability;
  • to report births and deaths and to participate in disease registries;
  • to report child abuse or neglect;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
• Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, only if you have agreed to such a release, except that your consent will not be required if the information disclosure has been ordered by a court of law.
• Law Enforcement. We may disclose medical information if asked to do so by a law enforcement official in the following situations:
  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • If the information is in regard to a victim of a crime, and if, under certain limited circumstances, we are unable to obtain the person's agreement to the disclosure;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at a Spectrum Health facility; and
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
• Coroners, Medical Examiners and Funeral Directors. We may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose medical information about patients of the hospital to funeral directors as necessary to carry out their duties.
• National Security and Intelligence Activities. We may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose medical information about you to the correctional institution or law enforcement official. This disclosure would be 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; or (3) for the safety and security of the correctional institution.
• To Third Parties. We may disclose your medical information to certain third parties with whom we contract to perform services on behalf of a Spectrum Health entity. If we do so, we will have written assurances from the third party that the third party will safeguard your information.
  

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. During an inspection of your information, a health professional may be in attendance to assist you. The information available to you includes medical and billing records, but does not include any psychotherapy notes.
  To inspect or obtain a copy of medical information that may be used to make decisions about you, you must submit your request in writing to the specific Spectrum Health facility or medical provider office that provided the related services. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies or other charges incurred or associated with your request.
  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. Another licensed health care professional chosen by Spectrum Health will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
• Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Spectrum Health.
  To request an amendment, your request must be made in writing and submitted to the Director of Health Information Management or the person responsible for the maintenance of medical records at the specific Spectrum Health facility or medical provider office that provided the related services. In addition, you must provide a reason that supports your request.
  We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for a Spectrum Health entity;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you.
  To request this list or accounting of disclosures, you must submit your request in writing to the Director of Health Information Management or the person responsible for medical records at the specific Spectrum Health facility or medical provider office that provided the related services. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs 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.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. All Spectrum Health facilities operate under this Joint Notice of Privacy Practices. Spectrum Health recognizes that you may wish to exercise your rights differently at various Spectrum Health facilities, such as a hospital, your physician office or outpatient treatment center. It is your responsibility as the patient to notify individual Spectrum Health facilities of specific restrictions to use or disclosure of your medical information. You must notify each specific Spectrum Health facility and make those restrictions known. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had to a certain person to whom disclosure would otherwise be permitted.
  We are not required to agree to your request to restrict our USE of your health information. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. You are entitled, however, to restrict DISCLOSURE of your medical record to a third party outside of the Spectrum Health facilities except: (1) as required because of transfer of your health care to another health care facility; (2) as required by law; or (3) as required by a third party payment contract. To request restrictions, you must make your request in writing to the affected Spectrum Health facility. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
• Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
  To request confidential communications, you must make your request in writing to the privacy official at the specific Spectrum Health facility from which confidential communications are requested. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
  You may obtain a copy of this Notice at our website, www.spectrum-health.org, or at any Spectrum Health facility.

CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the facilities covered by this Notice. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to a facility for treatment or health care services as an inpatient or outpatient, a copy of the current Notice in effect will be made available to you upon your request.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Spectrum Health entity involved or with the Secretary of the Department of Health and Human Services. To file a complaint with Spectrum Health or any Spectrum Health facility, contact the Spectrum Health Chief Patient Privacy and Information Security Officer at 100 Michigan Street NE, Grand Rapids, MI 49503, (616) 391-1273 or via e-mail at patient.privacy@spectrum-health.org.
All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION.
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to reverse any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

OGC/HIPAA/Privacy Notice - SH - Final
2/26/03