WBRMC Privacy Statement:
(Revised August 2016)
|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.
If you have any questions about this notice, please contact Cindy Miller,
Corporate Compliance and Privacy Officer at 343-3172.
Who Will Follow This Notice
This notice describes the practices of West Branch Regional Medical Center and the participants of the organized health care arrangement who provide care to patients of West Branch Regional Medical Center (WBRMC) and includes the following providers:
· Any health care professional authorized to enter information into your hospital chart
· All departments and units of WBRMC and the employees, medical staff, and other hospital personnel who provide services within these departments and units
· Medical Arts Center, 335 E. Houghton Avenue, West Branch, MI 48661
· Jill Jennings, MD, Physician Practice, 2333 Progress St., Suite A, West Branch, MI 48661
· Hospice of Helping Hands, Inc., 332 W. Houghton Avenue, West Branch, MI 48661
· Medical Arts Center Family Practice, 337 E. Houghton Avenue, Clinic B, West Branch, MI 48661
All these entities and providers will comply with the terms of this notice. In addition, these entities and providers may share medical information with each other for treatment, payment or health care operation purposes described in this notice.
We are obligated by law to protect your privacy and give you this notice of our privacy practices. This notice describes how we protect your protected health information and what rights you have regarding your protected health information. "Protected health information" means any of your written or oral health information, including demographic data that can be used to identify you.
Use or Disclosure of Your Protected Health Information
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 try to give an example. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclosure 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 health information about you to doctors, nurses, technicians, medical students or other hospital personnel who are involved in taking care of you at the hospital. Different departments of the hospital also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
· For Payment- We may use and disclose your health information to others for the purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third party payer, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.
· For Health Care Operations- We may use and disclose health information about you for operational purposes. These uses and disclosures are necessary to operate WBRMC and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose your health information to doctors, nurses, technicians and other hospital personnel for review and learning purposes. We may also combine health information about many hospital patients to decide what additional services WBRMC should offer.
- Medical Center Directory- We may include certain limited information about you in the medical center directory while you are a patient at WBRMC. This information may include your name, location in the medical center, your general condition (e.g., fair, stable, etc.) and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.
- Individuals Involved in Your Care or Payment for Your Care- Unless there is a specific written request from you to the contrary, we may release 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 helps pay for your care.
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.
- Appointments- We may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual.
- Treatment Alternatives, Health Related Benefits and Services- We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives, health related benefits or services that may be of interest to you.
- As Required By Law- We will disclose medical information about you when required to do so by federal, state or local law. For example, disclosure may be required by Workers' Compensation statutes and various public health statutes in connection with required reporting of births and deaths, certain diseases, child abuse and neglect, domestic violence, and adverse drug reactions.
- 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.
- Organ and Tissue Donation- Your health information may be used or disclosed for cadaver organ, eye or tissue donation purposes.
- Government Functions- Specialized government functions, such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.
- Workers' Compensation- We may release medical information about you in order to comply with laws and regulations related to Workers' Compensation.
- Public Health Risks- We may disclose medical information about you for public health activities, such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.
- 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.
- Coroners, Medical Examiners and Funeral Directors- We may release medical information to a coroner or medical examiner to enable them to carry out their lawful duties.
- Inmates- If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official.
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 authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, 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 take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.
Your Rights Regarding Health Information
Upon written request, you have the following rights regarding health information we maintain about you:
- The right to request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522; however, West Branch Regional Medical Center is not required to agree to a requested restriction except in the following circumstances. WBRMC is obligated to comply with a request to restrict disclosure to a health plan if the disclosure is for the purposes of carrying out payment or health care operations and is not otherwise required by law and you have paid WBRMC in full for the services WBRMC has provided. To request a restriction on the disclosure of your protected health information you must make your request in writing to the Corporate Compliance and Privacy Officer listed on page one;
- The right to obtain a paper copy of the notice of privacy practices upon request;
- The right to inspect and obtain a copy of your health record as provided for in 45 CFR 164.524;
- The right to request an amendment of your health record as provided in 45 CFR 164.526;
- The right to request that communications of your health information be provided by alternative means or at alternative locations;
- The right to opt out of receiving any fundraising communications from WBRMC;
- The right to revoke your authorization to use or disclose health information except to the extent that action has already been taken; and
- The right to receive an accounting of disclosures made of your health information as provided by 45 CFR 164.528
If you believe your privacy rights have been violated, you may file a complaint with the West Branch Regional Medical Center or with the Department of Health and Human Services. To file a complaint with the hospital, please submit a written complaint to:
Corporate Compliance and Privacy Officer
West Branch Regional Medical Center
2463 S. M-30
West Branch, MI 48661
Obligations of West Branch Regional Medical Center and the participants of its Organized Health Care Arrangement
We are required to:
- Maintain the privacy of protected health information;
- Provide you with this notice of its legal duties and privacy practices with respect to your health information;
- Abide by the terms of this notice;
- Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
- Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations;
- Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law; and
- Notify you of a breach of your unsecured protected health information.
We reserve the right to change our information practices and to make the provisions effective for all protected health information we maintain. We will make revised notices available to you by posting a copy of the current notice at West Branch Regional Medical Center. On the first page of the notice in the top right hand corner the notice will have the effective date. In addition, each time you register at or are admitted to West Branch Regional Medical Center for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice then in effect.
WBRMC Notice of Non-Discrimination:
West Branch Regional Medical Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
West Branch Regional Medical Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
West Branch Regional Medical Center:
· Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other formats)
· Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Cynthia K. Miller, Corporate Compliance Officer.
If you believe that West Branch Regional Medical Center has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Cynthia K. Miller, Corporate Compliance Officer, 2463 S. M-30, West Branch, MI 48661, phone (989) 343-3172, fax (989) 343-3244, email@example.com.
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Cynthia K. Miller, Corporate Compliance Officer is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (989) 343-3172.
رقم ) (989) 343-3172ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 1
. (989) 343-3172- ھاتف الصم والبكم:
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 (989) 343-3172。
ܢܿܘܬܼܝܠܒܼܿܩܕܢܘܿܬܝܼܨܡܵ،ܐܝܵܪܵܘܿܬܐܵܐܢܫܠܢܘܿܬܝܼܡܙܡܸܿܿܿܗܼܐܟܢܘܬܚܐܼܢܐ:ܐܪܗܘܙܵܵܿ.ܵܵܿܵܵܵܿܿܿ (989) 343-3172ܐܢܝܢܡܸܠܥܢܘܪܩܬܝܐܼܢܓܡܼܐܢܫܠܒܸܐܬܪܝܼܗܼܕܐܬܹܡܠܼܚܸܼܿ
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (989) 343-3172
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (989) 343-3172.
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. (989) 343-3172 번으로 전화해 주십시오.
লয্করনঃযিদআপিনবাংলা, কথাবলেতপােরন, তাহেলিনঃখরচায়ভাষাসহায়তাপিরেষবাউপলআেছ।েফানকরন১-(989) 343-3172.
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (989) 343-3172.
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (989) 343-3172.
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (989) 343-3172.
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (989) 343-3172.
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (989) 343-3172.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (989) 343-3172.