You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy. You have the right to
inspect and copy medical information that may be used to make decisions
about your care. Usually, this includes medical and billing records, but
may exclude records such as psychotherapy notes.
To inspect and copy medical information that may be used to make
decisions about you, you must submit your request in writing to our
Correspondence Desk in the Medical Records Department. See Contact List
Someone from this department will contact you within 30 days about your
request. If you request a copy of the information, we may charge a fee
for the costs of copying, mailing or other supplies associated with your
If your medical information is maintained in an electronic format (known
as an electronic medical record or an electronic health record), you
have the right to request that an electronic copy of your record be
given to you or transmitted to another individual or entity. We will
make every effort to provide access to your medical information in the
form or format you request, if it is readily producible in such form or
format. If the medical information is not readily producible in the form
or format you request, your record will be provided in either our
standard electronic format or, if you do not want this form or format, a
readable hard copy form. We may charge you a reasonable, cost-based
fee for the labor associated with transmitting the electronic medical
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information, you may,
under certain circumstances, request that the denial be reviewed.
Another licensed health care professional chosen by the 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.
Right to Amend. If you feel that medical information
we have about you is incorrect or incomplete, you may ask us to amend
the information. You have the right to request an amendment for as long
as the information is kept by or for the hospital.
To request an amendment, your request must be made in writing and
submitted to our Correspondence Desk in the Medical Records Department.
(See Contact List at end.) In addition, you must provide a reason that
supports your request. 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 us to amend information
- 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 medical information kept by or for the hospital.
- Is not part of the information which you would be permitted to inspect and copy.
- Is accurate and complete.
Right to an Accounting of Disclosures. You have the
right to obtain an “accounting of disclosures” for your health
information when such disclosures are made for other than treatment,
payment, or related administrative or operative purposes as described
To request an accounting of disclosures, you must submit your request in
writing to our Correspondence Desk in the Medical Records Department.
(See Contact List at end.) Your request must state a time period, which
may not be longer than six years and may not include dates before April
14, 2003. Your request should indicate in what form you want the list
(for example, on paper or 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
at that time before any costs are incurred.
Right to Request Restrictions. You have the right to
request a restriction or limitation on the medical information we use
or disclose about you for treatment, payment or health care operations
except when specifically authorized by you, when required by law, or
emergency circumstances. We are not required to agree to your request
unless you are asking us to restrict the use and disclosure of your
medical information to a health plan for payment or health care
operation purposes and such information you wish to restrict pertains
solely to a health care item or service for which you have paid us
“out-of-pocket” in full. If we do agree, we will comply with your
request unless the information is needed to provide you with emergency
To request restrictions, you must make your request in writing to our
Correspondence Desk in the Medical Records Department. 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
You do have the right to request a limit on the medical information we
disclose about you to those involved in your care, such as a family
member or friend. For example, you could ask that we not use or disclose
information about a surgery you had to your spouse. You will be given
the opportunity to request such a restriction at admission.
Right to Request Confidential Communications. You
have the right to request that we communicate with you about medical
matters in a certain way or at a certain location. For example, you can
ask that we only contact you at work or by mail. To request confidential
communications, you must notify hospital staff at the time of
registration or by calling or writing the Registration Department. (See
Contact List at end.)
We will not ask you the reason for you request. We will accommodate all
reasonable requests. Your request must specify how or where you wish to
Right to a Paper Copy of This Notice. You have the
right to a paper copy of this notice. You may ask us to give you a copy
of this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of this
notice. Contact the Medical Records Department. (See Contact List at
Right to Receive Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured medical information.
Organ and Tissue Donation. We may release medical
information to organizations that handle organ procurement or organ, eye
or tissue transplantation or to an organ donation bank, as necessary to
facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the
armed forces, we may release medical information about you as required
by military command authorities. We may also release medical information
about foreign military personnel to the appropriate foreign military
Workers’ Compensation. We may release medical
information about you for workers’ compensation or similar programs.
These programs provide benefits for work related injuries or illness.
Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
To prevent or control disease, injury or disability.
- To report births and deaths.
- To report child abuse or neglect.
- To report reactions to medications or problems with products.
- To notify people of recalls of products they may be using.
- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
- To notify 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.
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. These activities are
necessary for the government to monitor the health care system,
government programs and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a
lawsuit or a dispute, we may disclose medical information about you in
response to a court or administrative order. We may also disclose
medical information about you 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 protesting the information requested.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process.
- About a death we believe may be the result of criminal conduct.
- About criminal conduct at the hospital.
Coroners, Medical Examiners and Funeral Directors.
We may verbally release medical information to a coroner, medical
examiner or funeral director for the purpose of reporting a death,
identifying the deceased person or other duties. We may also release
your medical records to a coroner or medical examiner for the purpose of
determining the cause of death, but we will only do so with proper
authorization or pursuant to a court ordered subpoena.
National Security and Intelligence Activities. We
may release medical information about you to authorized federal
officials for intelligence, counterintelligence and other national
security activities authorized by law.
Protective Services for the President and Others. We
may disclose medical information about you to authorized federal
officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special
Inmates. If you are an inmate of a correctional
institution or under the custody of a law enforcement official, we may
release medical information about you to the correctional institution or
law enforcement official. This release would be necessary: (1) for the
institution to provide you with health care, (2) to protect your health
and safety or the health and safety of others, or (3) for the safety and
security of the correctional institution.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make
the revised or changed notice effective for medical information we
already have about you as well as any information we receive in the
future. We will post a copy of the current notice in the hospital. The
notice will contain the effective date on the back. This electronic
version contains the effective date at the end.
If you believe your privacy rights have been violated, you may file a
complaint with the hospital or with the US Department of Health and
Human Services/Office of Civil Rights. To file a complaint with the
hospital, contact the Patient Relations Department at (616) 394-3742.
You will not be penalized for filing a complaint.
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
permission. If you provide us permission to use or disclose medical
information about you, you may revoke that permission, in writing, at
any time. If you revoke your permission, 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 permission and that we
are required to retain our records of the care that we provided to you.