District Health Department 4

Serving Alpena, Cheboygan, Montmorency
and Presque Isle counties.

Privacy Practices

DISTRICT HEALTH DEPARTMENT NO. 4
NOTICE OF PRIVACY PRACTICES REGARDING HEALTH INFORMATION
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.

Understanding Your Health Record/Information

This Notice of Privacy Practices is to provide you adequate notice of your rights and, our legal duties and privacy practices with respect to the uses
and disclosures of protected health information. We will use or disclose protected health information in a manner that is consistent with this notice.
It also describes your rights to access and control your Protected Health Information (PHI).  PHI is information about you, including demographic 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. Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically this record contains your symptoms, examination and test results, diagnoses, treatment, assessments, physician orders, medication lists, progress notes, and a plan for current and future care or treatment. This information, often referred to as your health or medical record, serves as:

  • a basis for planning your care and treatment;
  • a means of communication among the many health professionals who contribute to your care;
  • a legal document describing the care you received;
  • a source of data for medical research;
  • a source of information for public health officials charged with improving the health of the nation;
  • a source of data for facility planning and marketing; and,
  • a tool which we can use to assess and improve the care we render and the outcomes we achieve (adequacy and appropriateness of care).

Understanding what is in your record and how your health information is used helps you to:

  • ensure its accuracy;
  • better understand who, what, when, where, and why others may access your health information; and,
  • make more informed decisions when authorizing disclosure to others.

We Have a Legal Duty to Protect Health Information About You

As required by law, we must maintain policies and procedures about our work practices, including how we provide and coordinate care provided to
our clients. These policies and procedures include how we create, maintain and protect medical records; how we govern access to medical information about our clients; how we maintain the confidentiality of all PHI related to our clients, including security of electronic files; and how we
educate staff on privacy of client information. We also must provide you with notice of all legal duties and privacy practices concerning your PHI.
Notices are posted in each office in a prominent location and copies are available upon request at each service delivery site for you to take with you. We will provide the notice no later than the date of your first service delivery except in the event of an emergency treatment situation, then as soon as reasonably practicable after the emergency treatment situation. We reserve the right to change our practices and the terms of this notice and to make the new provisions effective for all PHI we maintain. Should our information practices change, we will post a copy in each office and have copies available upon request. We will not use or disclose your health information without your authorization, except as described in this notice. When another federal or state law governs the use or disclosure of protected health information, then we will comply with the law.

Uses and Disclosures of Protected Health Information for Treatment, Payment and Health Operations

You will be asked to sign an acknowledgement, which indicates your receipt of this Notice of Privacy Practices. Once signed, your PHI may be used
and disclosed by our staff and others outside of our agency that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to receive payment for your health care service and support Agency operations. The following are examples of uses and disclosures of your PHI that this Agency is permitted to make with your acknowledgement of receipt of this
Notice. These examples are not meant to be exhaustive:

We will use your Protected Health Information for treatment.

Your PHI will be used to provide, coordinate or manage health care and related services, consultation between health care providers relating to you or, referral for health care from one provider to another. For example: We may fax your PHI to a physician or other health care provider to whom you have been referred to ensure they have the necessary information to diagnosis or treat you. We may provide your physician or a subsequent health care provider (such as any hospital, nursing home or other health care facility to which you may be admitted) with copies of various reports, and documents while currently providing service and/or after discharge from service that should assist him or her in treating you. We may also disclose PHI to individuals outside our Agency that may be involved in your medical care after you are discharged from our service (such as family members, clergy or others) to provide services that are part of your care.

We will use your Protected Health Information for payment.

Your PHI will be used, as needed, to obtain payment for your health care services. This includes billing and collecting for services provided, determining plan eligibility and coverage, utilization review, precertification and medical necessity review. For example: Occasionally the insurance
requests a copy of the medical record to be sent to them for review prior to paying the bill. A bill may be sent to you, your insurance company or
third-party health plan, Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, supplies, lab tests and results, medical history, and/or other related information.

We will use your Protected Health Information for regular healthcare operations.

Your PHI will be used for general Agency administrative and business functions, quality assurance/improvement activities; medical review; auditing
functions; developing clinical guidelines; determining the competence or qualifications of health care professionals; evaluating agency performance; conducting training programs with students or new employees; licensing, survey, certification, accreditation and credentialing activities; internal auditing and certain fundraising and marketing activities. For example: We may use PHI to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine PHI about many clients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical and nursing students, and other personnel for review and learning purposes to help them practice or improve their skills. We may also combine PHI we have with PHI from other health care agencies to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of PHI so others may use it to study health care and health care delivery without learning who the specific clients are.

We may use and disclose PHI without your authorization or opportunity to object.

We may use and/or disclose PHI about you for a number or circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include:

Public Health Activities: We may disclose information to state or federal public health authorities, as required by law to: prevent or control disease,

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We may disclose information to state or federal public health authorities, as required by law to: prevent or control disease, injury or disability; vital events such as births and deaths; public health surveillance; report child abuse or neglect; report reactions to medications or problems with products; notify persons of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

Abuse or Neglect: We may disclose your PHI to a public agency that is authorized by law to receive reports of child abuse or neglect. In addition, if

:
We may disclose your PHI to a public agency that is authorized by law to receive reports of child abuse or neglect. In addition, if we believe that you have been the victim of abuse, neglect or domestic violence we may disclose your PHI to the governmental entity or agency authorized to receive such information. In this case, the disclosure will only be made if you agree or when required or authorized by law.

Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse

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We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track FDA related products, to enable product recalls, repairs or replacements, or to conduct post marketing surveillance, as required.

Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections,

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We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, civil, administrative, or criminal proceedings or actions by a government health oversight agency to monitor the health care system, government benefit programs, other government regulatory programs and compliance with civil rights laws.

Judicial and Administrative Proceedings: We may disclose your PHI if you are involved in a lawsuit or a dispute. This disclosure may be in

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We may disclose your PHI if you are involved in a lawsuit or a dispute. This disclosure may be in response to an order of a court or administrative tribunal, court ordered warrant, summons issued by a judicial officer, or similar process, but only if efforts have been made to notify you about the request or an order was obtained protecting the information requested.

Law Enforcement: We may disclose your PHI, when applicable legal requirements are met, for law enforcement purposes. These law enforcement

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We may disclose your PHI, when applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include; identification or location of a suspect, fugitive, or missing person, pertaining to the victim of a crime, if under certain limited circumstances, we are unable to obtain the persons agreement, pertaining to a death we believe may be the result of criminal conduct, in good faith, in the event or evidence of criminal conduct at our location(s) and in emergency circumstances to report a crime, the location of the crime or victim(s), or the identity, description or location of the person who committed the crime.

Coroners, Funeral Directors and Organ Donation: We may disclose PHI to a coroner or medical examiner for identification purposes, determining

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We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death.

Cadaveric Organ, Eye or Tissue Donation: We may disclose your PHI to communicate with organizations in procuring, banking or transplanting

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We may disclose your PHI to communicate with organizations in procuring, banking or transplanting organs, eyes or tissue for the purposes of facilitating donation and transplantation (if you are an organ donor).

Research: We may disclose your PHI under very select circumstances for research. Before we disclose any of your PHI for such research purposes,

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We may disclose your PHI under very select circumstances for research. Before we disclose any of your PHI for such research purposes, the project will be subject to an extensive approval process including protocols to ensure the privacy of your PHI.

To Avert a Serious Threat to Health and Safety: We may disclose your PHI to prevent or lessen a serious and imminent threat to the health or safety

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We may disclose your PHI to prevent or lessen a serious and imminent threat to the health or safety of a person or the general public, such as when a person admits to participation in a violent crime or serious harm to a victim or is an escaped convict.  Any disclosure, however, would only be to someone able to help prevent or lessen the threat.

For Specialized Government Functions: We may disclose your PHI when appropriate conditions apply, for individuals involved in military and

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We may disclose your PHI when appropriate conditions apply, for individuals involved in military and veterans' activities, national security and intelligence activities, protective services for the President and others and medical suitability determinations.

Workers' Compensation: We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers

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We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Correctional Institutions and In Other Law Enforcement Custodial Situations: Should you be an inmate of a correctional institution, we may

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Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof PHI necessary for your health and the safety of other individuals.

You May Object to Certain Uses and Disclosures

We are permitted to use or disclose PHI about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:

  • We may use and/or disclose your name, and your condition described in general terms that does not communicate specific medical information in our client listing or directory, to members of the clergy and with people who ask for you by name. We also may share your
religious affiliation with clergy.

  • We may use and/or disclose with a family member, relative, friend or other person identified by you, PHI directly related to that person's
involvement in your care or payment for your care. We may share with a family member, personal representative or other person
responsible for your care, PHI necessary to notify such individuals of your location, general condition or death.

  • We may use and/or disclose PHI with a public or private agency (for example, American Red Cross) for disaster relief purposes. Even if
you object, we may still share the PHI about you, if necessary for the emergency circumstances. If you are not present or able to agree or
object to the use or disclosure of your PHI, then your provider may, using professional judgement, determine whether the disclosure is in
your best interest. In this case only the PHI that is relevant to your health care will be disclosed.

  • We may use and/or disclose PHI to registries such as the Michigan Childhood Immunization Registry (MCIR) when established protocols
ensure the privacy of your health information.
  • We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.
  • We may use and/or disclose PHI to manage or coordinate your healthcare. This may include telling you about treatments, services,
products and/or other healthcare providers. We may also use and/or disclose PHI to give you gifts of a small value. For example: If you
are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you.
  • We may use and/or disclose PHI about you, including disclosure to a foundation, to contact you to raise funds for the Agency and its
operations. We would only release contact information and the date you received treatment or services.

If you would like to object to our use or disclosure of PHI about you in the above circumstances, please contact our Privacy Officer.

Your Health Information Rights

Although your health record is the physical property of the Agency that compiled it, the information belongs to you. Following is a statement of your
rights with respect to your PHI and a brief description of how you may exercise these rights.

You have the right to:

  • Request restrictions on uses and disclosure of your protected health information.

    You may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care, the payment for your care or for notification purposes as described in this notice. We are not required to agree to any requested restriction you may request. If we believe it is in your best interest to permit use and disclosure of your PHI, it will not be restricted. If we do agree we will comply with your request unless the information needed is to provide you emergency treatment.To request restrictions, you must make your request in writing, utilizing the DHD#4 form "Request to Restrict the Use and Disclosure of Protected Health Information". These forms are available at any Health Department office or through request of your provider. Your request must include: what information you want to limit; whether you want to limit our use or disclosure or both; and to whom you want the limits to apply. Either you or we may terminate the restriction upon notification to the other.

  • Receive confidential communications of protected health information and request communications of your PHI by alternative means or at alternative locations. We will attempt to honor reasonable requests for confidential communication and will arrange for you to receive
protected health information by alternative means or at alternative locations. Your request must be in writing utilizing DHD#4 form "Request for Redirection of Confidential Communication". These forms are available at any Health Department office or through request of your provider. We do not require an explanation for the request as a condition of providing communications on a confidential basis.
  • Request to access your health record, you may inspect and/or obtain a copy of PHI about you, that is contained in a designated record set for as long as we maintain the PHI. A "designated record set" contains medical and billing records and any other records that we may use for making decisions about you.Under federal law, however, you may not inspect or copy the following records; psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed.To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing utilizing DHD#4 form "Request to Inspect and/or Copy Protected Health Information". These forms are available at any Health Department office or through your provider. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.If we deny access to your PHI, you will receive a timely, written denial that explains the basis for the denial, your review rights and an explanation of how to exercise those rights. If we do not maintain the medical record, we will tell you where to request the protected health information if known.

  • Request to amend protected health information, for as long as the PHI is maintained in the designated record set. A request to amend your record must be in writing to our Privacy Officer, utilizing DHD#4 form "Request to Amend Protected Health Information". These forms are
         available at any Health Department office or through your provider. You must also provide a reason that supports your request. In certain       cases, we may deny your request. If we deny your request, you have the right to submit a written statement disagreeing with the denial with our Privacy Officer and we may prepare a rebuttal to your statement and provide you with a copy.

  • Receive an accounting of disclosure of your protected health information. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operation as described in this notice. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.To request this list of accounting disclosures, you must submit your request in writing utilizing DHD#4 form "Request Protected Health Information - Accounting of Disclosure". These forms are available at any Health Department office or through your provider. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. If you request a list of disclosures more than once in 12 months, we may charge you a reasonable fee. 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.
  • Revoke your authorization to use or disclose PHI except to the extent that action has already been taken.
  • You have the right to obtain a paper copy of the notice upon request. You may ask us to give you a paper copy of this notice anytime even if you have agreed to receive this notice electronically.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Privacy Officer at 989-356-4507 or 1-800-221-0294.
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer or with the Secretary of Health and Human
Services. All complaints must be in writing. Health and Human Services can be contacted toll free at 1-877-696-6775 or by e-mail at

http://www.hhs.gov/contacts/. There will be no retaliation for filing a complaint.

There will be no retaliation for filing a complaint. This notice is effective April 14, 2003. We are required to abide by the terms of this notice currently in effect, but we reserve the right to change

We are required to abide by the terms of this notice currently in effect, but we reserve the right to change these terms as necessary for all PHI that we maintain.