Notice of Privacy Practices

Notice of Privacy Practices

Version No. 04142003.1
Effective Date: April 14, 2003


We at Battle Creek Health System (BCHS) are 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 are required to post this
Notice in a prominent place within our facilities. 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.

BCHS 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 BCHS will use and disclose your PHI.

This Notice applies to the delivery of health care by BCHS
and its medical staff in the main hospital, outpatient departments,
BCHS network Physicians/Providers’ offices, and clinics.
This Notice also applies to the utilization review and quality
assessment activities of Trinity Health and BCHS as a member
of Trinity Health, a Catholic health care system with facilities
in 7 states.

I. Permitted Use or Disclosure

a. Treatment: BCHS will use and disclose your PHI in the
provision and coordination of heath care to carry out treatment

  • BCHS 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.
  • BCHS is a Catholic sponsored health care provider. Spiritual
    care providers are members of our inpatient/outpatient care
    staff and will be part of BCHS’s team of care providers
    who use medical information to provide health care services
    to you when you are in BCHS’s facilities.
  • Different departments will share medical information about
    you in order to coordinate specific services such as lab
    work, x-rays and prescriptions.
  • BCHS also will disclose your medical information to people
    or entities outside BCHS who will be involved in your medical
    care after you leave BCHS; such as family members, clergy
    and others used to provide services that are part of your
  • BCHS 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 other health
    care providers.
  • BCHS will use and disclose your PHI to inform you of,
    or recommend possible treatment options or alternatives
    that will be of interest to you.
  • BCHS will use and disclose PHI to contact you as a reminder
    that you have an appointment for treatment or medical care
    at BCHS.
  • If you are an inmate of a correctional institution or
    under the custody of a law enforcement official, BCHS will
    disclose your PHI to the correctional institution or law
    enforcement official.

b. Payment: BCHS will release 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 treatment from your health plan.
  • BCHS will disclose to collection agencies and other subcontractors
    engaged in obtaining payment for care.

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

  • For instance, BCHS 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.

d. Other Uses and Disclosures: As part of treatment, payment
and helath care operations, we may also use your PHI for the
following purposes:

  • Fundraising Activities: BCHS may use and may also disclose
    some of your PHI for certain fund raising activities. For
    example, BCHS will use your demographic information (e.g.,
    name, address and other contact information, age, gender
    and insurance status) and the dates BCHS 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. BCHS may disclose limited PHI to a company
    contracted to conduct fundraising for BCHS. This company
    will use your PHI only for the purposes of fundraising for
    BCHS. (If you wish to opt out, you may do so by contacting
    the Privacy Official at (269) 966-8017.
  • Medical Research: BCHS 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: BCHS 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. BCHS
    will also send you information based on your own health
    concerns. BCHS 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 then under HIPAA and when under state law
the records are more protected from disclosures than under
HIPAA. Certain federal laws also are more stringent than HIPAA.
BCHS 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 the health information regarding substance
abuse treatment. In Michigan patients have more rights of
access to behavioral health information under 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 adapt 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: While you are a hospital patient BCHS
may disclose PHI about you to a friend or family member who
is involved in your medical care. BCHS will also give information
to someone who helps you pay for your care. In addition, BCHS
may 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 the right to request
that your PHI not be shared with some or all of your family
or friends.

b. BCHS Directory: BCHS will include certain limited information
about you in the BCHS Directory while you are a hospital patient
at BCHS. This information will include your name, location
in BCHS, your general condition (e.g., fair, stable, critical,
etc.) and your religious affiliation. This is so your family
and friends can visit you in BCHS and know how you are doing.
The directory information, except for you religion affiliation,
will also be disclosed to people who ask for you by name.
You have the right to request that you name not be included
in the BCHS directory. If you request to opt out of the facility
directory, we cannot inform visitors of your presence, location,
or general condition. In the event of your death, BCHS will
disclose the patient’s death and contact information
about funeral arrangements in response to a directory inquiry
after the patient’s next of kin have been notified.

c. Spiritual Care: Directory information including your religious
affiliation will be given to a member of the clergy, such
as a priest or rabbi, even if they don’t ask for you
by name. Your name, location and general condition will be
disclosed to members of the religious community. It is our
policy not to notify your local religious organization, by
disclosing your name, that you are in BCHS, and your condition.
A spiritual care provider may be called in to consult regarding
your care. Spiritual care providers are members of the health
care team at BCHS. You have a right to request that you name
not be given to any member of the clergy.

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

e. Media Conditions Reports: BCHS 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
and 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: BCHS is not permitted to provide your PHI to
any other person or company for marketing to you of any products
or services other than BCHS’s products or services unless
you have signed an authorization.

b. Research: BCHS 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,
BCHS may require that you sign an authorization to allow the
researchers to use and 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.

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

a. Law Enforcement Purposes: BCHS will disclose your PHI
for law enforcement purposes, such as responding to a court
order or subpoena, identifying a suspect or a missing person,
or providing information about a crime victim or criminal

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

c. Coroners, Medical Examiners, Funeral Directors: BCHS may
release your PHI to a coroner or medical examiner to identify
a deceased individual or to identify the cause of death. If
necessary, BCHS may also disclose PHI to funeral directors
as necessary to carry out their duties.

d. Organ Procurement: BCHS may release PHI to an organ procurement
organization or entity for organ, eye or tissue donation purposes.

e. Health or Safety: BCHS will use and disclose PHI to avert
a serious threat to health and safety of a person or the public.
BCHS will use and disclose PHI to Public Health Agencies for
immunizations, communicable diseases, etc. BCHS 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 purposes of tracking.

V. Your Health Information Rights

Although we at BCHS must maintain all records concerning
your hospitalization and/or treatment by BCHS, you have the
following rights concerning your PHI:

a. Right to Inspect and Copy: You have the right to inspect
and have copies of your PHI made for you as long as we maintain
it except for: information that will be used in a civil, criminal
or administrative action or proceeding and where prohibited
or protected by law. BCHS 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 BCHS
    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.
  • BCHS 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, BCHS will allow the review of its decision by a
    health care professional that BCHS 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 BCHS. BCHS will respond to your request within 30 days
    of its receipt. If BCHS cannot, BCHS will notify you in
    writing to explain the delay and the date by which we will
    act on your request. In any event, BCHS 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 BCHS maintains it. However, BCHS will deny your
request for amendment if:

  • BCHS did not create the information;
  • The information is not part of the designated record
  • The information would not be available for your inspection
    (due to its condition or nature); or
  • The information is accurate and complete.

If BCHS denies your request for changes in your PHI, BCHS
will notify you in writing with the reason for the denial.
BCHS will also inform you of your right to submit a written
statement disagreeing with the denial. You may ask that BCHS
include your request for amendment and the denial any time
that BCHS discloses the information that you wanted changed.
BCHS 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 BCHS, including your reason to support the requested amendment.
BCHS will respond to your request within 60 days of its receipt.
If BCHS cannot, BCHS will notify you in writing to explain
the delay and the date by which BCHS will act on your request.
In any event, BCHS 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 BCHS made,
except for the following disclosures:

  • To carry out treatment, payment or health care operations;
  • To you or authorized by you;
  • To persons involved in your care;
  • For national security or intelligence purposes;
  • To correctional institutions or law enforcement officials;
  • 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 the was one.

You must make your request for an accounting of disclosures
of your PHI in writing to BCHS. You must include the time
period of the accounting, which will not be longer than 6
years. BCHS will respond to your request within 60 days from
its receipt. If BCHS cannot, BCHS will notify you in writing
to explain the delay and the date by which BCHS will act on
your request. In any event, BCHS will act on your request
within 90 days of its receipt.

In any given 12-month period, BCHS will provide you with an accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting will be subject to a reasonable fee in 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. BCHS 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 BCHS only contact you at work or by mail.

f. 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 BCHS or with the Secretary of the Department of Health and Human Services. To file a complaint with BCHS, please contact the BCHS’s Privacy Officer at (269) 966-8017. All complaints must be submitted in writing directly to the BCHS’s Privacy Officer. 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 BCHS’s mission to improve the health of the community, BCHS will share your PHI with other organizations as described below whom have agreed to abide by the terms described below:

a. Medical Staff: The medical staff and BCHS participate together in an organized health care arrangement to deliver healthcare to you at BCHS. Both BCHS 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 BCHS. Physicians and allied health care providers are members of BCHS’s medical staff and will have access to and use you PHI for treatment, payment and health care operations purposes related to your care within BCHS. BCHS will disclose your PHI to the medical staff for payment, treatment and health care operations.

b. Business Associates: BCHS will use and disclose your PHI to business associates contracted to perform business functions on its behalf including Trinity Health, its parent who performs certain business functions for BCHS. Whenever, an arrangement between BCHS and another company involves the use and disclosure of your PHI, that business associate will be required to keep your information confidential.

c. Membership in Trinity Health: BCHS, members of Trinity Health and 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, and healthcare operations.
As a part of Trinity Health, a national Catholic health care system, BCHS 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 you PHI for your treatment, payment to BCHS and/or for the health care operations permitted by HIPAA with respect to our mutual patients.

  • BCHS will share your PHI with these organizations for purposes of your treatment, payment, and health care operations by these organizations.

VIII. Additional Information

For further information regarding the issues covered by this Notice of Privacy Practice, please contact: Privacy Official at 300 North Avenue Battle Creek, MI 49016 Phone No. (269) 966-8017.

XI. Changes to this Notice

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