Lakeshore Regional Entity
Notice of Privacy Practices
This notice describes how Lakeshore
Regional Entity may use and disclose Protected Health Information about you
and how you can get access to this information. Please review this notice
Effective date of this notice: February 16, 2015
This notice is being provided to you pursuant to the federal
law known as HIPAA and an amendment to that law, known as HITECH. If you have
any questions about this notice, please contact the Privacy Officer:
Apple Avenue; Muskegon, MI 48442
Other statutes and regulations, including, for example, the Michigan
Mental Health Code and Part 2 of Title 42 of the Code of Federal Regulations
may further restrict our use and disclosure of your Protected Health
Information. When that is the case, the greater restrictions or protections
Protected Health Information (PHI) is all individually
identifiable health information that is created or received by Lakeshore
Regional Entity that relates to your past, present or future physical or
mental health condition, the provision of health care services and payment for
those services. Examples of identifiable health information includes: your
name, address, telephone number and date of birth; your diagnosis (the
condition for which you are receiving treatment) and your treatment plan and
Our Pledge Regarding Your Protected
We understand that your health and medical information about
you is personal. We are required by law to maintain the privacy of your PHI, to
notify you following a breach of your unsecured PHI, and to provide you with
this notice of our legal duties and privacy practices with respect to your PHI.
This notice applies to the information we maintain concerning the services you
receive that are covered by the Lakeshore Regional Entity. Each service
provider may have different policies and/or notices regarding the use and
disclosure of your PHI created and provided by that service provider’s
This notice will tell you about the ways in which we may use
and disclose (share with others) your PHI. It also describes our obligation and
your rights regarding the use and disclosure of PHI.
How we May Use and Disclose PHI About
We may use and disclose PHI for a variety of reasons. We have
a limited right to use and/or disclose your PHI without your authorization for
the purpose of treatment, payment or our health care operations. Other uses and
disclosures require your written authorization unless the law permits or
requires us to make the use or disclosure without your authorization. If we
disclose your PHI to a third party in order for that party to perform a
function on our behalf, the third party must agree that it will extend the same
degree of privacy protection to your PHI that we do. Subject to the limitations
of the Michigan Mental Health Code, and Title 42, Part 2 of the Code of Federal
Regulations, we may use or disclose your PHI without your authorization as
Treatment. We may
use and disclose your PHI to health care providers under contract with Lakeshore
Regional Entity in order to provide and coordinate your health care and
related services. For example, we may disclose the needed parts of your PHI to
a Community Mental Health Agency that is involved in taking care of you.
Payment. We will disclose your PHI in order to
receive or make payment for the mental health and/or substance use disorder
treatment services provided to you. For example, we may disclose your PHI with
Medicaid and/or our contracted service providers to make sure services provided
to you are medically necessary and to facilitate and/or receive payment for the
treatment and services you receive.
Health Care Operations. We may use and disclose your PHI to support the business
activities of this agency (operations purposes). For example, we may use your
PHI in connection with: making sure we meet important goals and standards;
judging how well our employees do their job; training workers and volunteers;
licensing or accreditation of our agency; fraud and abuse detection programs;
business planning and development; and other general administrative activities.
Fundraising and Other Communications. We may use or disclose parts of your
PHI to offer you information that may be of interest to you. For example, we
may use your name and address to send you newsletters or other information
about activities. If we contact you to raise funds, we will inform you of our
intention and your right to opt out of receiving such communications.
Business Associates and
may contract with individuals and entities known as Business Associates to
perform various functions or provide certain services. In order to perform
these functions or provide these services, Business Associates may receive,
create, maintain, use and/or disclose your PHI, but only after they sign an
agreement with us requiring them to implement appropriate safeguards regarding
your PHI. Similarly, a Business Associate may hire a Subcontractor to assist in
performing functions or providing services in connection with your services. If
a Subcontractor is hired, the Business Associate may not disclose your PHI to
the Subcontractor until after the Subcontractor enters into a Subcontractor
Agreement with the Business Associate that also requires the Subcontractor to
safeguard your PHI.
Avert a Serious Threat to Health or
Safety. We may use
and disclose your PHI when necessary to prevent a serious threat to your health
and safety or the health and safety of the public or another person. Any
disclosure, however, would only be to someone able to help prevent the threat.
Public Health. We may disclose parts of your PHI to
the Public Health Department when the law requires us to do so. This disclosure
would only be made for the purpose of controlling disease, injury or
Health Oversight Entities. We may disclose your PHI to agencies
that are responsible for making sure our services meet quality standards. They
may need your PHI for activities such as audits, investigations and
inspections. Agencies that use this information may include the Centers for
Medicare and Medicaid Services and the Michigan Department of Community Health.
Law Enforcement. We will disclose your PHI when
required to do so by federal, state or local law. For example, we may disclose
PHI in the course of any court or administrative proceeding, if we are ordered
to do so and/or to meet legal requirements. We may also disclose PHI for law
enforcement purposes, such as investigation of a crime, but only if such
disclosures comply with Michigan law.
Food and Drug Administration. We may disclose your PHI if the Food and Drug Administration
requires it: for example, to report adverse events or product defects or
problems; help track products; and allow product recalls.
Coroners or Medical Examiners. We may disclose PHI to a coroner or medical examiner for
identification purposes, determining cause of death or for the coroner or
medical examiner to perform other duties.
Research Organizations/Individuals. We may disclose your PHI to researchers only with
Department of Health and Human Services (HHS). We must release your PHI to HHS so
they can make sure we are following the law. We also will release your PHI if
we suspect there may have been child or vulnerable adult abuse or neglect.
Federal and State Laws require these reports. Michigan law does not require us
to notify you when we make a report about abuse or neglect.
As Required by Law. We will disclose your PHI when required to do so by federal, state or
Your Rights Regarding
Your Protected Health Information (PHI)
You have the following rights regarding your PHI which we
have the right to inspect and receive a copy of your PHI. You have the right to
request access to the portion of your PHI that is contained in a designated
records set for as long as we maintain the PHI. “Designated record set” means
medical and billing records and any other records that this agency uses for
making decisions about you. This includes the right to inspect the information
as well as the right to a copy of the information. You may request that the
information be sent to a third party. You must submit a request for access in
writing to the Lakeshore Regional Entity Privacy Officer. If you request a
copy of the information, we may charge a reasonable fee for the costs of
copying, mailing or other supplies associated with your request (such as a
thumb drive in the case of a request for electronic information). We may deny
your request to inspect and copy in certain circumstances. If you are denied
access to medical information, you may request that the denial be reviewed by contacting our Privacy Officer.
If we maintain your PHI
electronically in a designated records set, we will provide you with access to
the information in an electronic form and format you request if readily
producible or, if not, in a readable electronic form and format as agreed to by
you and Lakeshore Regional Entity.
Under federal law you may not see or
copy the following that may be contained in your record: psychotherapy notes;
information gathered for use in court or at hearings; PHI that is covered by a
law that states you may not see it and/or information assigned or developed as
part of a peer review function.
Right to Amend. If you feel that PHI 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 Lakeshore Regional Entity.
To request an amendment, your request must be made in writing and submitted to
the Privacy Officer. In addition, you must provide a reason that supports your
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
- is not part of the treatment
information kept by Lakeshore Regional Entity;
- was not created by us, unless the
person or entity that created the information is no longer available to make
- is not part of the information which
you would be permitted to inspect and copy; or is accurate and complete.
Right to Request Restrictions. You have the right to request a
restriction or limitation regarding your PHI that we use or disclose for
treatment, payment or health care operations. You also have the right to
request a limit on your PHI that we disclose to someone who is involved in your
care or the payment for your care, like a family member or friend. To request
restrictions, you must make your request in writing to the Privacy Officer. In
your request, you must tell us: what information you want to limit, whether you
want to limit our use, disclosure or both, and to whom you want the limits to
We are not required to agree to your
request. Please discuss any restriction you wish to request with the Lakeshore
Regional Entity Privacy Officer.
Right to Request Confidential
have the right to request that we communicate with you about your services in a
certain way or at a certain location. For example, you can ask that we only
contact you at work or that we send mail to your Post Office box instead of
your home address. To request confidential communications you must make your
request in writing to the Privacy Officer. We will not ask you the reason for
your request. We will accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
Right to an Accounting of
have the right to request an accounting of certain disclosures of your PHI. The
accounting will not include disclosures to carry out treatment, payment and
health care operations, disclosures to you about your own PHI, disclosures
pursuant to an individual authorization or other disclosures as set forth in
HIPAA privacy policies and procedures. To request this list or accounting of
disclosures, you must submit your request in writing to the Privacy
Officer. Your request must state a time
period which may not be longer than six years. Your request should indicate in
what form you want the list (for example, paper or electronic). The first list
you request within a 12 month period will be free. For additional lists, we may
charge you for the reasonable 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.
Effective at the time prescribed by
federal regulations, you may also request an accounting of uses and disclosures
of your PHI maintained as an electronic health record.
Right to a Paper Copy of this Notice. Even if you received this notice
electronically, you have the right to a paper copy of this notice. You may ask
us to give you a paper copy of this notice at any time. To obtain a paper copy
of this notice, contact the Privacy Officer.
If we use or disclose PHI for underwriting purposes with
respect to your services, we will not use or disclose PHI that contains your genetic
information for such purposes.
Breach Notification Requirements
You have a right to be notified upon a breach of your
unsecured PHI. We will also inform HHS and take any other steps required by
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 PHI we already have
about you as well as any information we receive in the future. We will notify
you in the event of a change.
If you believe your privacy rights have been violated, you
may file a complaint with Lakeshore Regional Entity by contacting the Lakeshore
Regional Entity Privacy Officer.
Apple Avenue; Muskegon, MI 48442
You may also file a complaint with the Secretary of the U.S.
Department of Health and Human Services.
Your Written Permission
is Required for Other Uses and Disclosures of Your PHI
The following uses and disclosures of your PHI will be made
only with your written authorization:
and disclosures of PHI for marketing purposes;
that constitute a sale of your PHI; and
and disclosures of psychotherapy notes other than to carry out the treatment,
payment, and health care operations set forth at 45 CFR § 164.508(a)(2).
Other uses and disclosures of your PHI not covered by this
notice or applicable laws will be made only with your written permission. If
you provide us permission to use or disclose your PHI, you may revoke that
permission, in writing, at any time. If you revoke your permission, we will no
longer use or disclose your PHI 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.