IRON 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

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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.

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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 health information.
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 care services.

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.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN CONSENT

You 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:

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 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.·

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, 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 to you.

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 interest. ·

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 labels. ·

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. ·

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 its professional judgement to disclose that protected health information which it determines is reasonably necessary to provide for your care and treatment. ·

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. ·

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 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 authority.

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 programs.

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 laws.
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.

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. 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.