Notice of Privacy Practices

Pine Rest Christian Mental Health Services
Effective Date: April 14, 2003

THIS NOTICE DESCRIBES HOW PSYCHIATRIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Pine Rest Christian Mental Health Services provides psychiatric and medical care to patients in a number of locations. This notice applies to patients we treat in outpatient clinics and residential care facilities, but not inpatient, partial hospitalization and intensive outpatient programs. Pine Rest provides inpatient, partial hospitalization and intensive outpatient care in combination with Saint Mary's Mercy Medical Center. This notice does not apply to these patients cared for in this combined program - a separate notice applies to patients treated in these settings.

Who Will Follow These Practices:

1. Anyone who enters information into your Pine Rest records.
2. All locations, departments and services of Pine Rest.
3. Any volunteer at Pine Rest.
4. All employees and staff of Pine Rest.
5. Pine Rest Christian Mental Health Services.

Our Pledge: We are committed to protecting your psychiatric and medical information. We are required by State and Federal law to do the following:

1. Keep your personal health information private.
2. Give you this notice.
3. Follow the terms of the notice currently in effect.

We Are Allowed to Use and Disclose Your Psychiatric and medical Information:

1. To provide for psychiatric and medical treatment (example: our doctors, nurses and therapists will share information about you in order to provide you better care).
2. To receive payment for services provided to you (example: we will send a bill to your insurance company).
3. For quality improvement (example: we review charts to make sure quality care is given to our patients).
4. To remind you of an appointment (example: we may leave a message on your answering machine if you are not home).
5. With your permission, to individuals you want included in your care (example: you may approve sending your information to your family doctor or discussing your care with your family).
6. For a research project (example: a study on treatment effectiveness).
7. When required by law (example: reports we send to the Department of Public Health).

Special Situations

If one of the following situations applies to you, your information may be disclosed without your permission to the following organizations:

1. An organ donation center if you are a donor.
2. Community health, safety, and law enforcement officials, and those who may be at risk, in order to prevent a serious threat to the health and safety of you or others.
3. Health oversight agencies, if your psychiatric/medical record is selected for audit or inspection.
4. Law enforcement officials, but only under a judge's order, a search warrant, with your permission, or as necessary to fulfill our obligations as described in #2, above.
5. Coroners, medical examiners, and funeral directors, if a death occurs at our facility.
6. To a correctional facility, if you are an inmate.

In situations not outlined above, we will ask you for written authorization before disclosing your psychiatric and medical information. If you choose to sign an authorization, it can later be revoked to stop future disclosures.

Your Rights Regarding Your psychiatric and medical Information:

1. Right to Inspect and Copy. You have the right to inspect and obtain a copy of your records that we have. We may charge you a reasonable fee for copying your records. Under federal law, you may not inspect or obtain a copy of information that will be used in a civil, criminal, or administrative action or proceeding, or other information that is prohibited from disclosure by law. We may deny your request for certain specific reasons. In most cases, if we deny your request you may request our decision to be reviewed. For more information about your access to your records, please contact Pine Rest's Medical Records Director at 300 68th St. SE, Grand Rapids MI 49548 or (616) 455-5000.

2. Right to Request Restrictions. You have the right to request restrictions on how we use of your psychiatric and medical information for purposes of treatment, payment, or health care operations. We do not have to agree to these restrictions. If you wish to place restrictions on the use or disclosure of your psychiatric and medical information, please discuss this with Pine Rest's Medical Records Director at 300 68th St. SE, Grand Rapids MI 49548 or (616) 455-5000.

3. Right to Confidential Communications. You have the right to request that we communicate with you in a confidential manner. For example, you may request that we contact you only at work. If you wish to request confidential communications, please contact Pine Rest's Medical Records Director at 300 68th St. SE, Grand Rapids MI 49548 or (616) 455-5000.

4. Right to Amend. You have the right to amend your psychiatric/medical information for as long as we maintain it. If we did not create the psychiatric/medical information that you wish to amend, we may deny your request. If we deny your request, we will tell you why in writing and you will have the right to disagree with the denial in writing. For more information about amending your psychiatric/medical information, please contact Pine Rest's Director of Medical Records at 300 68th St. SE, Grand Rapids MI 49548 or (616) 455-5000.

5. Right to an Accounting. You have a right to receive a list of the persons or organizations with whom your psychiatric/medical information has been shared. This list will not include disclosures that have been made for treatment, payment, or health care operations purposes. It also will not include disclosures made to you, or family members or friends involved in your care. Nor will it include disclosures you approved in writing. If you wish to request this list of the disclosures of your psychiatric/medical information please contact Pine Rest's Director of Medical Records at 300 68th St. SE, Grand Rapids MI 49548 or (616) 455-5000.

6. Right to Receive a Copy of this Notice. You have a right to receive a paper copy of this Notice of Privacy Practices, upon request.

We are required by law to maintain the privacy of your psychiatric/medical information, provide you with this notice of our legal duties and privacy practices, and to abide by the terms of the version of this notice currently in effect.

For further information regarding your privacy rights or our privacy policies, please contact Pine Rest's Privacy Officer at P.O. Box 165, Grand Rapids, Michigan 49501, (616) 455-5000.

We reserve the right to change this notice at any time in the future, and these changes will apply to your information that we already have at the time of the change. The notice currently in force is always posted and available at our service locations, or on our web site: http://www.pinerest.org/hospital_privacynotice.html

If you believe your privacy rights have been violated, you may file a written complaint with Pine Rest's Privacy Officer at P.O. Box 165, Grand Rapids, Michigan 49501, or with the Secretary of the Department of Health and Human Services, 200 Independence Ave. SW, Washington, DC 20201. You will not be penalized for filing a complaint.