NOTICE OF PRIVACY PRACTICES LakeView Community Hospital Decatur Family Practice Mattawan Medical Center LakeView Medical Services 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 Notice of Privacy Practices (PDF format)      As a health care provider, LakeView Community Hospital and the related entities listed above access, create, edit, and maintain a record of your health information. This record contains information about your symptoms, examinations, test results, diagnoses, treatment, a plan for future care or treatment, and other information related to our provision of health care. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment; Means of communication among the many health professionals who contribute to your care; Legal document describing the care you received; Means by which you or a third-party payer can verify that services billed were actually provided; Tool in educating health professionals; Source of data for medical research; Source of information for public health officials who oversee the delivery of health care in the United States and the State of Michigan; Source of data for facility planning and marketing; and Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.      It is important that you understand what is in your record and how your health information is used, to ensure its accuracy, to better understand who, what, when, where, and why others may access your health information, and to make more informed decisions when authorizing disclosure to others. I.     Privacy and Confidentiality of Your Protected Health Information      Your personally identifiable health or medical information and record are called “Protected Health Information” in the remainder of this Notice.      This Notice describes the ways we may use and disclose your Protected Health Information. The Notice identifies the obligations we have regarding the use and disclosure of your Protected Health Information and your rights in regards to your Protected Health Information.      Our Notice of Privacy Practices applies to all records of your care that are created after the effective date of this Notice. Our legal obligations and duties apply whether the record was created by our staff or other medical professionals. However, other medical professionals not associated with us may have different policies or notices regarding their use and disclosure of your Protected Health Information. You should consult their Notice of Privacy Practices for information about how they may use and disclose your records. II.     Who Will Follow the Notice This Notice describes the privacy practices of LakeView Community Hospital including: All of its departments; All members of our workforce including volunteers, contractors, and agents; All healthcare professionals who enter information into our records; Physicians who provide services to patients at this hospital; and Physicians’ offices owned by LakeView Community Hospital including but not limited to Decatur Family Practice, Mattawan Medical Center, and LakeView Medical Services (Marcellus). In addition, these entities, sites, and professionals may share Protected Health Information for the purpose of treatment, payment, health care operations and other uses as described in this Notice. III.     Our Legal Duty We are required by law to: Maintain the confidentiality and privacy of Protected Health Information; Provide you with a notice of our legal duties and privacy practices with respect to Protected Health Information; Abide by the terms of the current Notice; Accommodate reasonable requests to communicate Protected Health Information by alternative means or at alternative locations.      We reserve the right to change our practices and to make the new provisions effective for all Protected Health Information we maintain. A copy of the revised Notice will be provided to you upon request at any of our facilities.      We will not use or disclose your Protected Health Information without your authorization, except as described in this Notice. HOW WE WILL USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION The instances where we may use and disclose your Protected Health Information are set forth below. This descriptive list is not exhaustive. However, the list describes the types of uses and disclosures that will be made. I.     Use and Disclosures without your written Authorization A.     Treatment: We will use your Protected Health Information for treatment purposes. Treatment includes the provision and coordination of health care (including risk assessment, case management, and disease management) by health care providers. It also includes the referral of a patient from one provider to another and coordinating care with a third party. For example, we will use your Protected Health Information to provide you with medical treatment or services. We may also disclose Protected Health Information to doctors, nurses, technicians, medical students, or other personnel involved in the provision of your care at LakeView Community Hospital. Protected Health Information may be disclosed to individuals involved in your medical care, such as family members or clergy. B.     Payment: We will use your Protected Health Information to obtain payment for our services. Payment activities are intended to obtain or provide reimbursement or payment for providing health care. This includes determining eligibility for coverage for insurance, collection activities, a review of services and the charges for the services, and the management of claims. For example, we will use and disclose Protected Health Information to bill and collect payment for the treatment and services you receive at LakeView Community Hospital and its entities. We may give your health plan information about the treatment you received. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. C.     Health Care Operations: We will use your Protected Health Information for our health care operations. Heath care operations consist of the administration of records, evaluation of health care professionals and the quality of treatment, assessment of the care and outcome of your case, and the business management of LakeView Community Hospital. For example, we may use Protected Health Information to review the treatment and services you received. We may also use Protected Health Information to evaluate new and current treatment and procedures. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and educational purposes. D.     Special Uses of Protected Health Information: Appointment Reminders: We may use and disclose Protected Health Information to contact you as a reminder that you have an appointment for treatment or medical care. For example, we may call to remind you of a scheduled surgery. Treatment Alternatives: We may use and disclose Protected Health Information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For example, we may describe to you alternative treatments for certain types of cancer. Health-Related Benefits and Services: We may use and disclose Protected Health Information to tell you about health-related benefits or services that may be of interest to you. For example, we may provide you with information on diet and exercise classes. Fundraising Activities: We may use Protected Health Information about you to contact you in an effort to raise money for LakeView Community Hospital and its operations. We may disclose Protected Health Information to a related foundation so that the foundation may contact you in raising money. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services. For example, we may contact you to donate to a particular part of the hospital. If you do not want LakeView Community Hospital to contact you for fundraising efforts, you must notify LakeView Community Hospital in writing. II.     Other Uses and Disclosures Without Your Written Authorization      We may use or disclose Protected Health Information for other reasons, even without your permission. Subject to certain requirements, we are permitted to give out health information without your permission for the following purposes: A.     As Required By Law We will disclose Protected Health Information when required by federal, state or local law. We are required by law to report gunshot wounds, suspected abuse or neglect, or similar injuries and events. B.     Public Health Activities We may disclose Protected Health Information for public health activities. These activities generally include, but are not limited to the following activities: Prevention or control disease, injury or disability; Reporting births and deaths; Reporting child abuse or neglect; Reporting reactions to medications or problems with products; Notifying people of recalls of products they may be using; Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. C.     Food and Drug Administration (FDA) We may disclose to the FDA Protected Health Information relevant to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. D.     Victims of Abuse, Neglect or Domestic Violence We may, as required by law, disclose Protected Health Information to the appropriate government agency if we reasonably believe you are the victim of abuse, neglect, or domestic violence, but only if we believe it is necessary to prevent serious harm to you or another person. E.     Health Oversight Activities We may disclose Protected Health Information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, disciplinary actions, and licensing. F.     Lawsuits and Disputes We may disclose Protected Health Information in response to an order of a court or administrative body. The disclosure will be limited to only the information requested in the order. We may also disclose Protected Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. G.     Law Enforcement We may release Protected Health Information to law enforcement officials under the appropriate conditions. For example: Responding to a court order, subpoena, court ordered warrant, summons issued by a judicial officer or similar process; Identifying or locating a suspect, fugitive, material witness, or missing person; Disclosing information about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s authorization; Releasing information concerning a death we believe may be the result of criminal conduct; Evidence of criminal conduct at our location; and Reporting a crime, the location or victims of the crime, or the identity, description or location of the person who committed the crime. H.     Coroners, Medical Examiners and Funeral Directors We may release Protected Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release Protected Health Information to funeral directors as necessary to carry out their duties. I.     Cadaveric Organ, Eye and Tissue Donation We may disclose Protected Health Information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. J.     Research Under certain circumstances, we may use and disclose Protected Health Information for research purposes. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of Protected Health Information in an attempt to balance the needs of the research program with patients’ right of privacy. K.     To Avert a Serious Threat to Health or Safety We may, consistent with applicable law and standards of ethical conduct, use and disclose Protected Health Information when necessary to prevent or lessen a serious and imminent threat to the health and safety of the public, another person, or your person. Any disclosure will be to someone able to help prevent the threat. L.     National Security, Intelligence Activities, and Military Functions We may release Protected Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities. If you are a member of the armed forces, we may release information as required by military command authorities. M.     Protective Services for the President and Others We may disclose Protected Health Information to authorized federal officials for the provision of protection to the President, other authorized persons such as foreign heads of state, or to conduct special investigations. N.     Inmates We may release Protected Health Information to a correctional institution or law enforcement official if the release is necessary (1) for the provision of health care; (2) to protect the health and safety of an individual or the health and safety of others; (3) for the safety and security of the correctional institution; (4) to conduct law enforcement at the institution; or (5) for the administration, safety, security and the good order of the institution. O.     Workers’ Compensation We may release Protected Health Information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness. P.     Business Associates There are some services provided in our organization through contacts with other entities. These other entities are our business associates. Examples of our business associates include accountants, consultants, and attorneys. We may disclose Protected Health Information to our business associates in the course of the performance of their respective jobs. We will protect your health information by requiring the business associates to appropriately safeguard your information to prevent use or disclosure of the information other than as permitted or required by contract. III.     Uses and Disclosures Requiring the Patient to Agree or Object:      You have the opportunity to agree to or object to the following uses and disclosures of your Protected Health Information. If you are not able or available to agree or object to the use or disclosure of your Protected Health Information, we may disclose information that is directly relevant to your care if, in the exercise of professional judgment, we determine it would be in your best interest to disclose the information. A.     Facility In-Patient Directories We may include certain limited information in our patient directory. This information may include your name, location, your general condition and your religious affiliation. We may also use your name on a nameplate over your bed. B.     Individuals Involved in Your Care or Payment for Your Care We may release Protected Health Information to a friend, family member, or any person whom you may designate 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 Protected Health Information to an entity assisting in a disaster relief effort in order to notify someone as to your condition, status and location. C.     Communication With Family We may disclose to a family member, relative, close personal friend, or any other person you identify, Protected Health Information relevant to that person’s involvement in your care or payment related to your care. If we are unable to reach your family member or personal representative, then we may leave a message for them, such as on an answering machine, at the phone number they have provided. YOUR INDIVIDUAL RIGHTS      You have the right to view, copy, request a change, amend, and restrict your Protected Health Information. Your rights are listed below with a brief description of the right and how you may exercise the right. Please contact the person named at the end of the Notice in the section “Contact Person” to obtain the appropriate forms for exercising these rights. A.     Inspect and Obtain Copy You have the right to examine and obtain a copy of Protected Health Information that may be used to make decisions about your care. This information may include but is not limited to medical and billing records. However, you do not have a right to examine psychotherapy notes, information compiled in reasonable anticipation of or use in a civil, criminal or administrative action or proceeding, or Protected Health Information that is subject to or exempt from the Clinical Laboratories Improvements Amendments of 1988. If you request a copy of the Protected Health Information, you must do so in writing. You also must specify the format, paper or electronic, in which you request to receive a copy of your Protected Health Information. If we are unable to provide a copy in the requested electronic format, we will provide a hard paper copy to you. We may charge a fee for the costs of copying (including labor), mailing or other supplies associated with your request. A summary of your Protected Health Information may be provided to you instead of a complete copy of your Protected Health Information. A summary may only be provided if agreed upon in advance by you and LakeView Community Hospital. There may be a charge for the creation of the summary. You will be notified in advance of any charge for the preparation of a summary. We may deny a request to inspect and copy Protected Health Information in certain circumstances. In some instances, if you are denied access to Protected Health Information, you may request that the denial be reviewed. Another licensed health care professional, chosen by LakeView Community Hospital, will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. B.     Amend Information If you feel that your Protected Health Information is incorrect or incomplete, you have the right to request that we correct the existing information or add the missing information. The reasons supporting your request must be provided. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; Is not part of the Protected Health Information kept by or for LakeView Community Hospital; Is not part of the information which you would be permitted to inspect or copy; or Is accurate and complete. C.     Accounting of Disclosures You may request a list of instances, or an accounting, where we have disclosed Protected Health Information about you for reasons other than treatment, payment, and health care operations. Your request must state a time period for which you would like to receive an accounting. The period may not be longer than six (6) years prior to the date of your request. The request may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred. We will provide you with the accounting no later than thirty (30) days after your request for all Protected Health Information that is maintained or accessible at LakeView Community Hospital or its affiliated entities. However, for information that is not maintained or accessible at LakeView Community Hospital or its affiliates, the accounting will be provided to you no later than sixty (60) days after the receipt of your request. We may, upon providing you with proper notice, extend the deadline by 30-days. D.     Request Restrictions You may request restrictions on certain uses and disclosures of your Protected Health Information. You may request a limit on the Protected Health Information disclosed to someone who is involved in your care or the payment for your care; for instance, a family member or friend. For example, you could ask that we not use or disclose information relating to a surgery. We are not required to agree to your request. If we do agree, we must abide by those restrictions unless the information is needed to provide you emergency treatment. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply; for example, disclosures to your spouse. The restriction may be terminated by you or LakeView Community Hospital upon proper notification of the other party. E.     Confidential Communications You may ask us to communicate with you about medical matters confidentially by, for example, contacting you at work, sending Notices to a special address, or not using postcards to remind you of appointments. We will not ask you the reason for your request. We will accommodate all reasonable requests. However, your request must specify how or where you wish to be contacted. CHANGES TO THIS NOTICE We will change this Notice as necessary and appropriate to comply with changes in the law and our policies. We will post a copy of the current Notice in the Registration area. You may also request a copy of our Notice at any time. For more information about our privacy practices, contact the person listed below. COMPLAINTS If you are concerned that your privacy rights have been violated or want to file a complaint, you may contact the persons listed below. All complaints must be submitted in writing. You may also send a written complaint to the U.S. Department of Health and Human Services. You will not be penalized in any way for filing a complaint. CONTACT PERSON If you have any questions or requests about this Notice, please contact: Title:          Privacy Officer Phone:      269-657-1469 If you have a complaint, please contact: Title:          Compliance Officer Phone:      269-657-1525 OTHER USES OF PROTECTED HEALTH INFORMATION Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide permission to use or disclose Protected Health Information, you may revoke that permission at any time. A revocation must be submitted in writing. If you revoke your permission, we will no longer use or disclose Protected Health Information for the reasons covered by your written authorization. EFFECTIVE DATE The effective date of this Notice is: April 14, 2003 LV-75 (04/03)

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