COUNTY MEDICAL CARE FACILITY
VICTORIAN HEIGHTS ASSISTED LIVING
Dr. Robert F. Han, Medical Director (ICMCF), Dr. Donald
W. Smith, Medical Director (ICMCF/CM), Dr. Roger Untalan, Dr. Ronald
Dalton, Dr. Terrance Kearney, Dr. Kim Mahler
JOINT NOTICE OF PRIVACY PRACTICES FOR PROTECTED 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.
Please review this Notice carefully and contact Sharon Leonoff (hereafter
"the Facility's Privacy Officer") with any questions or concerns that
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 you rights to access and control your protected
Protected health information is defined by law to include demographic
information that may identify you and that relates to your past, present,
or future physical or mental health or condition and related health
We are required to abide by the terms of this privacy notice. Iron
County Medical Care Facility and Iron County Medical Care Facility/Crystal
Manor (hereafter "the Facility") may change the terms of its notice
at any time. The new notice will be effective for all protected health
revised notice of privacy practices. Copies are available in the following
locations: the main lobby magazine rack, and Public bulletin board
located in East corridor across from the elevator.
AND DISCLOSURE OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN
will be asked by the Facility to sign a consent form. Once you consent
to the disclosure of your protected health information for treatment,
payment, and health care operations by signing the consent form, 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, by others outside the Facility and 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 exhausted, but only describe the type of uses and disclosures
that may be made by the Facility to which you have provided consent:
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 and 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, as they may need access to the information to
provide care for you. We may also disclose protected health information
to specialists or laboratories that may become involved in your care.·
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, to make determinations of
eligibility for coverage for insurance group benefits, and for determination
of whether services are medically necessary.
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, marketing and fundraising
activities, and conducting or arranging for other business activities.
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.
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
The Facility may also use and disclose protected information for other
marketing activities. 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 send to you. ·
OTHER PERMITTED OR REQUIRED USES OR 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
judgement to make those disclosures which it deems to be in your best
FACILITY RESIDENT DIRECTORY/
Family/Clergy/Other Postings/Other Disclosures
Unless you object, the Facility will use and disclose your name in
the Facility directory, in the Facility newsletter, on fire drill
clipboards, on memory/remembrance boards, and on birthday calendars.
Your general condition may be disclosed to family members and your
religious affiliation to members of the clergy. If you receive therapy
services, your name may be posted on a treatment board in a therapy
room. In addition, your name will appear on meal tickets and snack
OTHERS INVOLVED IN HEALTH-CARE
Unless you object, the Facility may disclose to a member of your family,
relative, close friend or any other person you identify, protected
health information that directly relates to that person's 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 its professional judgement.
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. ·
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 its professional judgement to disclose that
protected health information which it determines is reasonably necessary
to provide for your care and treatment. ·
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. ·
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 judgement, that you would consent
to the use or disclosure under the circumstances.
OTHER PERMITTED AND REQUIRED USES THAT MAY BE MADE WITHOUTH YOUR CONSENT,
AUTHORIZATION, OR OPPORTUNITY TO OBJECT.
DISCLOSURES AUTHORIZED BY LAW
The Facility may use or disclose protected health information in the
following situations without your consent or authorization.
These situations include:
1. Required by law. The Facility may use or disclose protected health
information to extent that law requires the use or disclosure. 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
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 audits, investigations, and inspections. Oversight agencies seeking
this information include government agencies which oversee the health-care
system, government benefit programs, and other government regulatory
5. Abuse or neglect. The Facility may disclose protected health information
to a 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 proceedings. 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 result of criminal conduct; and good faith belief that 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.
If you are an organ donor, 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 and safety of a person
of the public. The Facility may disclose protected 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 you are a member of that
foreign military service. The Facility will also disclosure 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
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 decision about you.
To inspect and copy your health information, you must submit your
request in writing to the facility's privacy officer. If you request
a copy of this information, we may charge a fee for the cost of copying,
mailing, or other supplies associated with your request. The first
accounting that you request within a twelve month period will be free.
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 record.
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 prohibited health information for purposes of treatment, payment
or health 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
no 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
agrees with the request restriction, the Facility will not use or
disclose your protected health information unless it is needed to
provide emergency treatment. With this in mind, please discuss any
restriction request with the Facility's Privacy Officer. ·
AMENDMENT OF RECORDS
You have the right to receive any amendment to your 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 we maintain the 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 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. Your written request must state
the time period, which may not be longer than six years prior to the
date of your request, and may not include dates before 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.
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. All complaints should be submitted in writing to
either the Facility's Privacy Officer or Administrator. The Facility's
Privacy Officer can be contacted at (906) 875-6671 ext. 219, or in
writing at: Iron County Medical Care Facility Attn: Sharon Leonoff
1523 Hwy. U.S. 2 Crystal Falls, MI 49920 The Facility will not retaliate
against any person who makes a complaint under this Policy. This Notice
was published by the Facility on April 01, 2003 and became effective
on April 14, 2003.