Westshore Family Medicine

Notice Of Privacy Practices

Version No.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 at Mercy General He alth Partners are required by law to maintain the privacy of individually identifiable patient health information (this information is "protected health information" and is referred to herein as "PHI"). We are also required to provide patients with a Notice of Privacy Practices regard ing PHI. We are required to post this Notice in a prominent place within our facilities. 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.

Mercy General Health Partners understands 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 Mercy General Health Partners will use and disclose your PHI.

This Notice applies to the delivery of health care by Mercy General Health Partners, its medical staff in the hospital, outpatient departments, retail pharmacy, MGHP Ambulatory Site s, Nextcare Hospitals/Muskegon, Inc., a Michigan corporation dba Lifecare Hospitals of Western Michigan, and the Regional Delivery Network of West Michigan.

This Notice also applies to the utilization review and quality assessment activities of Trinity Health and Mercy General Health Partners as a member of Trinity Health, a Catholic health care system with facilities in 7 states.

I. Permitted Use or Disclosure

A. Treatment: Mercy General Health Partners will use and disclose your PHI in the provision and coordination of heath care to carry out treatment functions.

Mercy General Health Partners will disclose all or any portion of your patient medical record information to 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.

Mercy General Health Partners is a Catholic sponsored health care provider. Spiritual care providers are members of our inpatient /outpatient care staff and will be a part of Mercy General Health Partners' team of care providers who use your medical information to provide health care services to you when you are in Mercy General Health Partners' facilities.

Different departments will share medical information about you in order to coordinate specific services, such as lab work, x-rays and prescriptions.

Mercy General Health Partners will also disclose your medical information to people or entities outside Mercy General Health Partners who will be involved in your medical care after you leave Mercy General Health Partners; such as family members, clergy (for hospital patients

only) and others who will provide services that are part of your care.

Mercy General Health Partners 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.

Mercy General Health Partners will use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.

Mercy General Health Partners will use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at a Mercy General Health Partners facility.

If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Mercy General Health Partners will disclose your PHI to the correctional institution or law enforcement official.

B. Payment: Mercy General Health Partne

rs will disclose PHI about you

for the purposes of determining coverage, eligibility, funding, billing, claims management, medical data processing, stop loss / reinsurance and reimbursement.

The 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 s haring the necessary information to obtain pre-approval for payment for treatment from your health plan.

Mercy General Health Partners will disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.

C. Health Care Operati ons: Mercy General Health Partners will use and disclose your PHI during routine health care operations including quality assurance, utilization review, med ical review, internal auditing, accreditation, certification, licensing or credentialing activities of Mercy General Health Partners, and for educatio nal purposes.

For instance, Mercy Ge neral Health Partners 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 patients 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 m ay also use your PHI for the following purposes:

Fundraising Activities: Mercy General Health Partners may use and disclose some of your PHI to a related foundation for certain fund raising activities. For example, Mercy General Health Partners may use your demographic information (e.g., name, address and other contact information, age, gender and insurance status) and the dates Mercy General Health Partners provided service to you. Any communication sent to you will let you know how you may opt out of receiving similar communications in the future. Mercy General Health Partners may disclose limited PHI to a company contracted to conduct fundraising for Mer cy General Health Partners. This company will use your PHI only for the purpos es of fundraising for Mercy General Health Partners. (If you wish to opt-out, you may do so by contacting the Privacy Official at (231)

672-3761)

Medical Research: Mercy General Health Partners 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 thro ugh a special approval process before any PHI is disclosed to the researchers. Researchers will be required to safeguard the PHI they receive.

Information and Health Promotion Activities: Mercy General Health Partners may use and disclose so me of your PHI for certain health promotion activities. For example, your name and address may be used to send you newsletters or general communications. Mercy General Health Partners may also send you information based on your own hea lth concerns. Mercy General Health Partners may send you this information if it has determined that a product or service may help you. The communication will explain how the product or service relates to your well being and can impro ve your health.

E. More Stringent Stat e and Federal Laws: The State law of Michigan is more stringent than HIPAA in sev eral areas. State law is more stringent when the individual is entitled to great er 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. Mercy General Health Partners will continue to a bide by these more stringent state and federal laws. The federal laws include applicable Internet privacy laws, su ch as the Children's Online Privacy Protection Act and the federal laws and regulations governing the confidentiality of health information regarding substance abuse treatment.

Patients have more rig hts of access to behavioral health information under Michigan law than under HIPAA and the state law defines a minimum necessary standard for release of mental he alth information. Disclosure is permitted with consent, and for treatment without consent in an emergency. Minors in Michigan have more rights to confidentia lity and protection of certain information (reproductive health, behavioral heal th and substance abuse) than under HIPAA. State law requires facilities to ado pt policies regarding release of information outside the facility. If the faci lity policy requires consent for release, then consent will be required. State l aw genetic and HIV testing and disclosure consents remain in place.

II. Permitted Use or Disclosure with an Opportunity for You to Agree or Object

A. Family/Friends: Whi le you are a hospital patient Mercy General Health Partners may disclose PHI about you to a friend or family member who is involved in your medical care. Mercy General Health Partners may also give information to someone who helps you pay for your care. In addition, Mercy General Health Partners may 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 famil y or friends.

B. Mercy General Health Partners' Directory: Mercy General Health Partners will include certain lim ited information about you in Mercy General Health Partners Directory while you are a hospital patient at Mercy General Health Partners. This information will include your name, location in Mercy General Health Partners, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliati on. This is so your family and friends can visit you in Mercy General Health Partners and know how you are doing. The directory information, except for your religious affiliation, will also be disclosed to people who ask for you by name. You have the right to request that your name not be included in Mercy General Health Partners Directory. If you request to opt out of the Facility Directory, we cannot inform visitors of your presence, location or general condition. In the event of your death, Mercy General Health Partners will disclose the patient's death and contact information about funeral arrangem ents in response to a directory inquiry after the patient's next of kin have been notified.

C. Spiritual Care: Unl ess you object, directory information including your religious affiliation may be given to a member of the community clergy even if they don't ask for you by name. Your name, location and general condition may be disclosed to members of the community clergy.

A hospital employed spiritual care provider may be called in to consult regarding your care. Spiritual care providers are members of the health care team at Mercy Gener al Health Partners. You do have the right to request that your name not be giv en to any member of the community clergy.

D. Promotional Communications: Mercy General Health Partners does not share or sell your P HI to companies that market health care products or services directly to consu mers for use by those companies to contact you, such as drug companies. Mercy General Health Partners does maintain a database of individuals for promoti onal communications, disease management, health promotion and fundraising purpos es. This database may include individuals to whom Mercy General Health Partners may have sent health improvement materials and news about Mercy General Health Partners previously and also individuals who have donated to Mercy General Health Partners or who have expressed an interest in donating to Mercy General Health Partners or other health-related activities. You may be included in this database. Mercy Gene ral Health Partners sends information to the individuals in this database about the programs and services of Mercy General Health Partners. If you wish to be deleted from this database, you may notify the Privacy Official of Mercy General Health Partners.

E. Media Conditions Re ports: Mercy General Health Partners may release information for an update to the media if the media requests information about you using your full name and after we have given you an opportunity to agree or object. The following in formation may then be

disclosed: your condit ion described in general terms that do not communicate specific medical information, such as "good", "fair", "serious" ; or "critical".

III. Use or Disclosure Requiring Your Authorization

A. Marketing: Mercy Ge neral Health Partners is not permitted to provide your PHI to any other person or company for marketing to you of any products or services other than the Mer cy General Health Partners'

products or services u nless you have signed an authorization.

B. Research: Mercy Gen eral Health Partners will use or disclose your PHI as part of research that incl udes providing you with treatment. For example, if you are part of a research st udy that includes treatment, Mercy General Health Partners may require that you sign an authorization to allow the researchers to use or disclose your PHI for this research.

C. Other Uses: Any use s 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 w hy 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 Pur poses: Mercy General Health Partners will disclose your PHI for law enforcement purposes as required by law, such as responding to a court order or subpoen a, identifying a criminal suspect or a missing person, or providing information about a crime victim or criminal conduct.

Required by Law: Mercy General Health Partners will disclose PHI about you when required by federa l, state or local law to make reports or other disclosures. Mercy General Heal th Partners also will make disclosures for judicial and administrative proceed ings such as lawsuits or other disputes in response to a court order or subpoena. Mercy General Health Partners will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violen ce. Mercy General Health Partners will report drug diversion and information related to fraudulent prescription activity to law enforcement and regulato ry agencies. Specialized government functions will warrant the use and disclos ure of PHI. These government functions will include military and veteran's activit ies, national security and intelligence activities, and protective services for the President and others. Mercy General Health Partners will make certain disclosures that are required in order to comply with workers' compensation or similar programs.

B. Coroners, Medical Examiners, Funeral Directors: Mercy General Health Partners may release PHI to a medical examiner or coroner to identify a deceased individual or to ident ify the cause of death. If necessary, Mercy General Health Partners may also disclose PHI to funeral directors as necessary to carry out their duties.

C. Organ Procurement: Mercy General Health Partners may disclose PHI to an organ procurement organizati on or entity for organ, eye or tissue donation purposes.

D. Health or Safety: M ercy General Health Partners will use and disclose PHI to avert a serious threat to health and safety of a person or the public. Mercy General Health Partners will use and disclose PHI to Public Health Agencies for immunizations, communica ble diseases, etc.

Mercy General Health Partners 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 patient receiving a medi cal device subject to FDA tracking requirements may refuse to disclose, or refu se permission to disclose, their name, address, telephone number and social security number or other identifying information for the purpose of trackin g.

V. Your Health Informa tion Rights

Although we at Mercy G eneral Health Partners must maintain all records concerning your hospitalization a nd/or treatment by Mercy General Health Partners, you have the following rights concerning your PHI:

A. Right to Inspect and Copy: You have the right to access your PHI and to inspect and copy your PH I 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. Mercy General Health Partners will deny your request for access to your PHI without giving you a n opportunity to review that decision if:

You don't have the rig ht to inspect the information; or it is otherwise prohibited or protected by law; You are an inmate at a correctional institution and obtaining a copy of the information would risk the health, safety, security, custody or rehabilitat ion of you or other inmates; The disclosure of the information would threaten t he safety of any officer, employee or other person at the correctional institu tion or who is responsible for transporting you; You are involved in a clinical research project and Mercy General Health Partners 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; Mercy General Health Partners obtained the information that you seek access to, from someone oth er than the health care provider under a promise of confidentiality and your access request is likely to reveal the source of the information; or Under other limited circumstances. In these instances, however, Mercy General Hea lth Partners will allow the review of its decision by a health care professional that Mercy General Health Partners has chosen.

This person will not h ave been involved in the original decision to deny your request.

You agree to pay a reasonable copying charge. If you are requesting PHI related to services received as a hospital patient, you must make your requests to access and c opy your PHI in writing to Mercy General Health Partners Attn: Medical Records Department. If you are requesting medical records from an ambulatory site, you must send the written request to that site. Attn: Medical Record Department. Mercy General Health Partners will respond to your request within 30 days of its receipt. If Mercy General Health Partners cannot, Mercy General Health Partners will notify you in writing to explain the delay and the date by wh ich we will act on your request. In any event, Mercy General Health Partners wi ll 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 Mercy General Health Partners maintains it. However, Mercy General Health Partners will deny your request for amendment if:

Mercy General Health Partners did not create the information; The information is not part of the designated record set; The information would not be available for your inspection (due to its condition or nature); or After validation, the documented information is accurate and complete.

If Mercy General Health Partners denies your request for changes in your PHI, Mercy General Health Partners will notify you in writing with the reason for the denial. Mercy General Health Partners will also inform you of your right to submit a writ ten statement disagreeing with the denial. You may ask tha t Mercy General Heal th Partners include your request for amendment and the denial any time Mercy General Health Partners discloses the information that you wanted changed. Mercy General Health Partners may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.< /span>

You must make your req uest for amendment of your PHI in writing to Mercy General Health Partners, including your reason to support the requested amendment. Mercy General Hea lth Partners will respond to your request within 60 days of its receipt. If Mer cy General Health Partners cannot, Mercy General Health Partners will notify y ou in writing to explain the delay and the date by which Mercy General Health Partners will act on your request. In any event, Mercy General Health Partn ers will act on your request within 90 days of its receipt.

C. Right to an Account ing: You have a right to receive an accounting of the Disclosures of your PHI th at Mercy General Health Partners made, except for the following disclosures:

To carry out treatment, payment or health care operations; To you or authorized by you; To persons involved in your care; For national security or intelligence purposes; To correctional institutions or law enforcement officials; or That occurred pr ior to April 14, 2003.

For each disclosure, y ou 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 f or an accounting of disclosures of your PHI in writing to Mercy General Health Partners. You must include the time period of the accounting, which may not be longer than 6 years. Mercy General Health Partners will respond to your req uest within 60 days from its receipt. If Mercy General Health Partners cannot, M ercy General Health Partners will notify you in writing to explain the delay and the date by which Mercy General Health Partners will act on your request. In any event, Mercy General Health Partners will act on your request within 90 day s of its receipt.

In any given 12-month period, Mercy General Health Partners 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: 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; Restricting specific informati on to only specified family members, relatives, close personal friends or other individuals involved in your care; or Limited information in the facility directory.

For example, you may a sk that your name not be used in the waiting room or that information about yo ur expected discharge date not be shared with your family. Mercy General Health Partners will consider your request but is not required to agree to the requested restrictions.

E. Right to Confidenti al 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 Mercy General Health Partners only contact you at work or by m ail.

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.

VI. Complaints

If you believe your pr ivacy rights have been violated, you may file a complaint with Mercy General Heal th Partners or with the Secretary of the Department of Health and Human Servic es. To file a complaint with Mercy General Health Partners, please contact Mercy General Health Partners' Privacy Official, at (231) 672-3761. All complaints must be submitted in writing directly to Mercy General Health Partners' Pri vacy Official. Mercy General Health Partners assures you that there will be no retaliation for filing a complaint.

VII. Sharing and Joint use of your Health Information

In the course of provi ding care to you and in furtherance of Mercy General Health Partners' mission to improve the health of the community, Mercy General Health Partners will sha re your PHI with other organizations as described below whom have agreed to ab ide by the terms described below:

A. Medical Staff: The medical staff and Mercy General Health Partners participate together in an organized health care arrangement to deliver health care to you at Mercy General Health Partners. Both Mercy General Health Partners and its medical staff 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 M ercy General Health Partners. Physicians and allied health care providers are members of Mercy General Health Partners' medical staff and will have acces s to and use your PHI for treatment, payment and health care operations purposes related to your care within Mercy General Health Partners. Mercy General He alth Partners will disclose your PHI to the medical staff for payment, treatment and health care operations.

B. Business Associates: Mercy General Health Partners will use and disclose your PHI to business as sociates contracted to perform business functions on its behalf including Trinity Health, its parent who performs certain business functions for Mercy General Health Partners.

Whenever an arrangement between Mercy General Health Partners and another company involves the use or disclosure of your PHI, that business associate will be required to keep yo ur information confidential.

C. Membership in Trini ty Health:

Mercy General Health Partners, members of Trinity Health and Trinity Health participate together in an organized health care arrangement for utilization review and quality assessment activities. We have agreed to abide by the terms of this Notice with respect to PHI created or received as part of utilization review and quality assessment activities of Trinity Health and its members. Members of Trinity Health will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or healthcare operations. As a part of Trinity Health, a national Catholic health care system, Mercy General Health Partners and other hospitals, nursing homes and health care providers in Trinity Health share your PHI for utilization review and quality assessment activities of Trinity Health, the parent company, and its members. Members of Trinity Health also use your PHI for your treatment, payment to Mercy Gener al Health Partners and/or for the health care operations permitted by HIPAA wi th respect to our mutual patients.

D. Regional Delivery N etwork of West Michigan:

Mercy General Health P artners may use and disclose medical information about you for regular health care operations, including those of the Regional Delivery Network of West Michig an, and organized health care arrangement in which we participate, for activiti es including, but not limited to, assessment of the care and outcomes in your case; quality and utilization assessment and improvement programs; medical review and education; financial risk management; and administration. As par t of those activities, your medical information may be combined with medical information from other health care providers, although we may remove information that identifies you so that others may use it to study health c are and its delivery without learning the identities of specific patients.

Mercy General Health Partners will share your PHI with these organizations for purposes of your treatment, payment and health care operations by these organizations.< /o:p>

VIII. Additional Infor mation

For further information regarding the issues covered by this Notice of Privacy Practice; please con tact the Privacy Official at 1500 E. Sherman Blvd., Muskegon, MI 49444, Phone No. (231) 672-3761.

IX. Changes to this No tice

Mercy General Health Partners will abide by the terms of the Notice currently in effect. Mercy General Health Partners reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintai ns. Mercy General Health Partners will provide you with the revised Notice at y our first visit following the revision of the Notice.