Trinity Continuing Care Services
NOTICE OF PRIVACY PRACTICES
Version Number 04142003.1
Effective Date: April 14, 2003
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.
We are required by law to maintain the privacy of individually
identifiable resident health information (this information
is "protected health information" and is referred in
this document as "PHI"). We are also required to provide
residents with a Notice of Privacy Practices regarding
PHI. We are required to post this Notice in a prominent
place within our facility. We will only use or disclose
your PHI as permitted or required by applicable state
law. This Notice applies to your PHI in our possession
including the medical records generated by us.
We understand that your health information is highly
personal, and we are committed to safeguarding your
privacy. Please read this Notice of Privacy Practices
thoroughly. It describes how we will use and disclose
This Notice applies to the delivery of health care
by this facility, its parent, Trinity Continuing Care
Services (TCCS), and the facility's medical directors
and clinical staff. This Notice also applies to the
utilization review and quality assessment activities
of TCCS as a member of Trinity Health, a Catholic health
care system with facilities in 7 states.
I. Permitted Use or Disclosure
A. Treatment: We will use and disclose your PHI in
the provision and coordination of heath care to carry
out treatment functions.
- We will disclose all or any portion of your resident
medical record information to our medical directors,
your attending physician, consulting physician(s),
nurses, technicians, medical students and other health
care providers who have a legitimate need for such
information in your care and continued treatment.
- This facility is a Catholic sponsored health care
provider. Spiritual care providers are members of
our care staff and will be a part of the team of care
providers who use your medical information to provide
health care services to you when you are in this facility.
- We will share medical information about you in order
to coordinate specific services, such as lab work,
x-rays and prescriptions.
- We also will disclose your medical information to
people or entities outside TCCS who will be involved
in your medical care during and after you leave this
facility, such as family members, clergy and others
who will provide services that are part of your care.
- We will share certain information such as your name,
address, employment, insurance carrier, emergency
contact information and appointment scheduling information
in an effort to coordinate your treatment with us
and with other health care providers.
- We will use and disclose your PHI to inform you
of, or recommend possible treatment options or alternatives
that will be of interest to you.
B. Payment: We will disclose PHI about you for the
purposes of determining coverage, eligibility, funding,
billing, claims management, medical data processing,
stop loss / reinsurance and reimbursement.
- Medical information will be disclosed to an insurance
company, third party payer, third party administrator,
health plan or other health care provider (or their
duly authorized representatives) involved in the payment
of your medical bill and will include copies or excerpts
of your medical records which are necessary for payment
of your account. It will also include sharing the
necessary information to obtain pre-approval for payment
for treatment from your health plan.
- We will disclose PHI to collection agencies and
other subcontractors engaged in obtaining payment
C. Health Care Operations: We will use and disclose
your PHI during routine health care operations including
quality assurance, utilization review, medical review,
internal auditing, accreditation, certification, licensing
or credentialing activities, and for educational purposes.
- For instance, we will need to share your demographic
information, diagnosis, treatment plan and health
status for population based activities relating to
improving health or reducing health care costs, protocol
development, case management and care coordination,
and contacting health care providers and residents
with information about treatment alternatives, in
order for us to operate our business in an efficient,
safe and legal manner.
D. Other Uses and Disclosures: As part of treatment,
payment and health care operations, we may also use
your PHI for the following purposes:
- Birthday celebrations and other activities related
to the residential nature of our facility.
- Taking and displaying photos of residents throughout
the building to help our facility feel more like a
- We may also use and disclose some of your PHI for
- Medical Research: We may disclose your PHI without
your authorization to medical researchers who request
it for approved medical research projects; however,
with very limited exceptions such disclosures must
be cleared through a special approval process before
any PHI is disclosed to the researchers. Researchers
will be required to safeguard the PHI they receive.
- We will use and disclose some of your PHI for certain
health promotion activities. For example, your name
and address may be used to send you newsletters or
E. See State specific detail at the end of the Notice
of Privacy Practices.
II. Permitted Use or Disclosure with an Opportunity
for You to Agree or Object
A. Family/Friends: We will disclose PHI about you to
a friend or family member who is involved in your medical
care. We will also give information to someone who helps
you pay for your care. In addition, we will disclose
PHI about you to an agency assisting in a disaster relief
effort so that your family can be notified about your
condition, status and location. You have a right to
request that your PHI not be shared with some or all
of your family or friends.
B. Resident Roster: We will include certain limited
information about you in the Resident Roster for this
facility while you are a resident. This information
will include your name, room number, your general condition
(e.g., fair, stable, critical, etc.) and your religious
affiliation (if you want this included). This is so
your family and friends can visit you and know how you
are doing. The Resident Roster, except for your religious
affiliation, will also be disclosed to people who ask
for you by name. The Resident Roster also will be used
by other residents. You have the right to request that
your name not be included in the Resident Roster. If
you request to opt out of the Resident Roster, we cannot
inform visitors of your presence, location, or general
condition. We generally disclose the resident's death
and contact information about funeral arrangements in
response to a Resident Roster inquiry after the resident's
next of kin have been notified.
C. Spiritual Care: Resident Roster information including
your religious affiliation will be given to a member
of the clergy, such as a priest or rabbi, if they request
information about our residents. We may notify your
local religious organization, by disclosing your name
that you are at this facility and your condition. A
spiritual care provider may be called in to consult
regarding your care. Spiritual care providers are members
of the health care team at this facility. You have a
right to request that your name not be given to any
member of the clergy.
D. Promotional Communications: We do not share or sell
your PHI to companies that market health care products
or services directly to consumers for use by those companies
to contact you, such as drug companies. TCCS does maintain
a database of residents for promotional communications,
disease management, health promotion, and fundraising
purposes. This database includes residents to whom we
may have sent news about this facility previously and
also residents who have donated to or who have expressed
an interest in donating to our facility. You may be
included in this database. If you wish to be deleted
from this database, you may notify the Administrator
at this facility.
III. Use or Disclosure Requiring Your Authorization
A. Marketing: We are not permitted to disclose your
PHI for marketing to you of any other company's products
or services unless you have signed an authorization.
B. Research: We may use or disclose your PHI as part
of research that includes providing you with treatment.
For example, if you are part of a research study that
includes treatment, we may require that you sign an
authorization to allow the researchers to use or disclose
your PHI for this research.
C. Other Uses: Any uses or disclosures that are not
for treatment, payment or operations and that are not
permitted or required for public policy purposes or
by law will be made only with your written authorization.
Written authorizations will let you know why we are
using your PHI. You have the right to revoke an authorization
at any time.
IV. Use or Disclosure Permitted by Public Policy
or Law without your Authorization
A. Law Enforcement Purposes: We will disclose your
PHI for law enforcement purposes as required by law,
such as responding to a court order or subpoena, identifying
a criminal suspect or a missing person, or providing
information about a crime victim or criminal conduct.
Required by Law: We will disclose PHI about you when
required by federal, state or local law to make reports
or other disclosures. We also will make disclosures
for judicial and administrative proceedings such as
lawsuits or other disputes in response to a court order
or subpoena. We will disclose your medical information
to government agencies concerning victims of abuse,
neglect or domestic violence. We will report drug diversion
and information related to fraudulent prescription activity
to law enforcement and regulatory agencies. Specialized
government functions will warrant the use and disclosure
of PHI. These government functions will include military
and veteran's activities, national security and intelligence
activities, and protective services for the President
and others. We will make certain disclosures that are
required in order to comply with workers' compensation
or similar programs.
B. Coroners, Medical Examiners, Funeral Directors:
We will disclose your PHI to a coroner or medical examiner.
For example, this may be necessary to identify a deceased
person or to determine a cause of death. We will also
disclose your medical information to funeral directors
as necessary to carry out their duties.
C. Organ Procurement: We may disclose PHI to an organ
procurement organization or entity for organ, eye or
tissue donation purposes.
D. Health or Safety: We will use and disclose PHI to
avert a serious threat to health and safety of a person
or the public. We will use and disclose PHI to Public
Health Agencies for immunizations, communicable diseases,
etc. We will use and disclose PHI for activities related
to the quality, safety or effectiveness of FDA-regulated
products or activities, including collecting and reporting
adverse events, tracking and facilitating product recalls,
etc. and post marketing surveillance. Any resident receiving
a medical device subject to FDA tracking requirements
may refuse to disclose, or refuse permission to disclose,
their name, address, telephone number and social security
number, or other identifying information for the purpose
V. Your Health Information Rights
Although we must maintain all records concerning your
treatment at this facility, you have the following rights
concerning your PHI:
A. Right to Inspect and Copy: In addition to your rights
as a resident of a nursing facility, you have the right
under HIPAA to access your PHI and to inspect and copy
your PHI as long as we maintain it except for: psychotherapy
notes, information that will be used in a civil, criminal
or administrative action or proceeding, and where prohibited
or protected by law. We will deny your request for access
to your PHI without giving you an opportunity to review
that decision if:
- You don't have the right to inspect the information;
or it is otherwise prohibited or protected by law;
- Disclosing the information would threaten the safety
of any person who is responsible for transporting
- You are involved in a clinical research project
and we created or obtained the PHI during that research.
Your access to the information will be temporarily
suspended for as long as the research is in progress;
- We obtained the information that you seek access
to from someone other than the health care provider
under a promise of confidentiality and your access
request is likely to reveal the source of the information;
- Under other limited circumstances. In these instances,
however, we will allow the review of its decision
by a health care professional that we have chosen.
This person will not have been involved in the original
decision to deny your request.
Under HIPAA, we request that you make your requests
to copy your PHI in writing to us. We are required by
HIPAA to respond to your request within 30 days of its
receipt. However, under other laws, you are entitled
to see your records within 24 hours (excluding hours
occurring during a weekend or holiday) after making
such a request. If we cannot provide the copies within
30 days, we will notify you in writing to explain the
delay and the date by which we will act on your request.
In any event, we will act on your request within 60
days of its receipt.
B. Right to Amend: You have the right to amend your
PHI for as long as this facility maintains it. However,
we will deny your request for amendment if:
- We did not create the information;
- The information is not part of the designated record
- The information would not be available for your
inspection (due to its condition or nature); or
- The information is accurate and complete.
If we deny your request for changes in your PHI, we
will notify you in writing with the reason for the denial.
We will also inform you of your right to submit a written
statement disagreeing with the denial. You may ask that
we include your request for amendment and the denial
any time that we disclose the information that you wanted
changed. We may prepare a rebuttal to your statement
of disagreement and will provide you with a copy of
You must make your request for amendment of your PHI
in writing to this facility, including your reason to
support the requested amendment. We will respond to
your request within 60 days of its receipt. If we cannot,
we will notify you in writing to explain the delay and
the date by which we will act on your request. In any
event, we will act on your request within 90 days of
C. Right to an Accounting: You have a right to receive
an accounting of the disclosures of your PHI that we
have made, except for disclosures:
- To carry out treatment, payment or health care operations;
- To you;
- To persons involved in your care;
- For national security or intelligence purposes;
- To correctional institutions or law enforcement
- That occurred prior to April 14, 2003.
For each disclosure, you will receive: the date of
the disclosure, the name of the receiving organization
and address if known, a brief description of the PHI
disclosed and a brief statement of the purpose of the
disclosure or a copy of the written request for the
information, if there was one.
You must make your request for an accounting of disclosures
of your PHI in writing to this facility. You must include
the time period of the accounting, which may not be
longer than 6 years. We will respond to your request
within 60 days from its receipt. If we cannot, we will
notify you in writing to explain the delay and the date
by which we will act on your request. In any event,
we will act on your request within 90 days of its receipt.
In any given 12-month period, we will provide you with
an accounting of the disclosures of your PHI at no charge.
Any additional requests for an accounting within that
time period will be subject to a reasonable fee for
preparing the accounting.
D. Right to Request Restrictions: Under HIPAA you have
the right to request restrictions on certain uses and
disclosures of your PHI to carry out treatment, payment
or health care operations functions or to prohibit such
disclosure. We will consider your request but may not
be able to fully act on your request.
E. Right to Confidential Communications: You have the
right to receive confidential communications of your
PHI by alternative means or at alternative locations.
For example, you may request that we only contact you
at work or by mail.
F. Right to Receive a Copy of this Notice: You have
the right to receive a paper copy of this Notice of
Privacy Practices, upon request.
If you believe your privacy rights have been violated,
you may file a complaint with this facility, it parent,
TCCS, or with the Secretary of the Department of Health
and Human Services. To file a complaint with this facility,
please contact the Administrator. To file a complaint
with TCCS, please contact TCCS's Privacy Officer indicated
below. All complaints must be submitted in writing directly
to these individuals. We assure you that there will
be no retaliation for filing a complaint.
Trinity Continuing Care Services
Attn: Julie Gutzmann, Privacy Officer
PO Box 9185
Farmington Hills, MI 48333-9185
Or contact by telephone: (248) 305-7605
VII. Sharing and Joint use of your Health Information
In the course of providing care to you and in furtherance
of our mission to improve the health of the community,
we will share your PHI with other organizations as described
below who have agreed to abide by the terms described
A. Medical Directors: The medical director(s) of this
facility and this facility participate together in an
organized health care arrangement to deliver health
care to you. Both this facility and the medical directors
have agreed to abide by the terms of this Notice with
respect to PHI created or received as part of delivery
of health care services to you in this facility. Medical
directors will have access to and use your PHI for treatment,
payment and health care operations purposes related
to your care. We will disclose your PHI to the medical
directors for payment, treatment and health care operations.
B. Business Associates: We will use and disclose your
PHI to business associates contracted to perform business
functions on its behalf including TCCS, its parent who
performs certain business functions for our facility.
Whenever an arrangement between this facility and another
company involves the use or disclosure of your PHI,
that business associate will be required to keep your
C. Membership in Trinity Health:
As a part of Trinity Health, a national Catholic health
care system, TCCS, other nursing homes, hospitals, and
health care providers in Trinity Health share your PHI
for utilization review and quality assessment activities
of Trinity Health. All members of Trinity Health have
agreed to abide by this Notice in sharing your PHI.
D. Affiliations: TCCS is affiliated with Trinity Home
Health Services (THHS) that is also owned by Trinity
Health. TCCS will share your PHI with THHS for purposes
of your treatment, payment and health care operations.
VIII. Additional Information
For further information regarding the issues covered
by this Notice of Privacy Practice, please contact the
XI. Changes to this Notice
We will abide by the terms of the Notice currently
in effect. We reserve the right to change the terms
of its Notice and to make the new Notice provisions
effective for all PHI that it maintains. We will provide
you with the revised Notice within 60 days following
a material change, or at your first visit following
the revision of the Notice.
E. More Stringent State and Federal Laws: The State
law of Maryland is more stringent that HIPAA in several
areas. State law is more stringent when the individual
is entitled to greater access to records than under
HIPAA and when under state law the records are more
protected from disclosure than under HIPAA. Certain
federal laws also are more stringent than HIPAA. We
will continue to abide by these more stringent state
and federal laws. The federal laws include applicable
Internet privacy laws, such as the Children's Online
Privacy Protection Act and the federal laws and regulations
governing the confidentiality and access of nursing
home clinical records, and confidentiality of health
information regarding substance abuse treatment.
In Maryland patients have greater rights to access
their medical records than under HIPAA. Minors in Maryland
have more rights to confidentiality and protection of
certain information, including drug abuse, alcoholism,
venereal disease, pregnancy, and contraception. Except
in certain circumstances, the patient's authorization
to disclose medical records may not exceed one year.
All of Maryland's state laws regarding its consent requirement
continue to apply. State law also allows the disclosure
of PHI regarding the following specific conditions:
birth defects, cancer, communicable diseases (including
sexually transmitted diseases) genetic testing, HIV
/ AIDS testing and mental health.