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 Bronson Battle Creek 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 regarding 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.

Bronson Battle Creek 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 Bronson Battle Creek will use and disclose your PHI.

This Notice applies to the delivery of health care by Bronson Battle Creek and its medical staff in the main hospital, outpatient departments, Bronson Battle Creek network Physicians/Providers' offices, and clinics. This Notice also applies to the utilization review and quality assessment activities of Trinity Health and Bronson Battle Creek as a member of Trinity Health, a Catholic health care system with facilities in 7 states.

I. Permitted Use or Disclosure

a. Treatment: Bronson Battle Creek will use and disclose your PHI in the provision and coordination of heath care to carry out treatment functions.

• Bronson Battle Creek 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.
• Bronson Battle Creek is a Catholic sponsored health care provider. Spiritual care providers are members of our inpatient/outpatient care staff and will be part of Bronson Battle Creek's team of care providers who use medical information to provide health care services to you when you are in Bronson Battle Creek's facilities.
• Different departments will share medical information about you in order to coordinate specific services such as lab work, x-rays and prescriptions.
• Bronson Battle Creek also will disclose your medical information to people or entities outside Bronson Battle Creek who will be involved in your medical care after you leave Bronson Battle Creek; such as family members, clergy and others used to provide services that are part of your care.
• Bronson Battle Creek 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 other health care providers.
• Bronson Battle Creek will use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.
• Bronson Battle Creek will use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at Bronson Battle Creek.
• If you are an inmate of a correctional institution or under the custody of a law enforcement official, Bronson Battle Creek will disclose your PHI to the correctional institution or law enforcement official.

b. Payment: Bronson Battle Creek will release 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 sharing the necessary information to obtain pre-approval for treatment from your health plan.
• Bronson Battle Creek will disclose to collection agencies and other subcontractors engaged in obtaining payment for care.

c. Health Care Operations: Bronson Battle Creek 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 of Bronson Battle Creek, and for educational purposes.

• For instance, Bronson Battle Creek 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 may also use your PHI for the following purposes:

• Fundraising Activities: Bronson Battle Creek may use and may also disclose some of your PHI for certain fund raising activities. For example, Bronson Battle Creek will use your demographic information (e.g., name, address and other contact information, age, gender and insurance status) and the dates Bronson Battle Creek 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. Bronson Battle Creek may disclose limited PHI to a company contracted to conduct fundraising for Bronson Battle Creek. This company will use your PHI only for the purposes of fundraising for Bronson Battle Creek. (If you wish to opt out, you may do so by contacting the Privacy Official at (269) 245-8017.
• Medical Research: Bronson Battle Creek 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.
• Information and Health Promotion Activities: Bronson Battle Creek will use and disclose some of your PHI for certain health promotion activities. For example, your name and address will be used to send you newsletters or general communications. Bronson Battle Creek will also send you information based on your own health concerns. Bronson Battle Creek 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 improve your health.

e. More Stringent State and Federal Laws: The State law of Michigan is more stringent than HIPAA in several areas. State law is more stringent when the individual is entitled to greater access to records then under HIPAA and when under state law the records are more protected from disclosures than under HIPAA. Certain federal laws also are more stringent than HIPAA. Bronson Battle Creek 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 of the health information regarding substance abuse treatment. In Michigan patients have more rights of access to behavioral health information under release of mental health information. Disclosure is permitted with consent and for treatment without consent but only in an emergency. Minors in Michigan have more rights to confidentiality and protection of certain information (reproductive health, behavioral health and substance abuse) than under HIPAA. State law requires facilities to adapt policies regarding release of information outside the facility. If the facility policy requires consent for release, then consent will be required. State law 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: While you are a hospital patient Bronson Battle Creek may disclose PHI about you to a friend or family member who is involved in your medical care. Bronson Battle Creek will also give information to someone who helps you pay for your care. In addition, Bronson Battle Creek 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 the right to request that your PHI not be shared with some or all of your family or friends.

b. Bronson Battle Creek Directory: Bronson Battle Creek will include certain limited information about you in the Bronson Battle Creek Directory while you are a hospital patient at Bronson Battle Creek. This information will include your name, location in Bronson Battle Creek, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation. This is so your family and friends can visit you in Bronson Battle Creek and know how you are doing. The directory information, except for you religion affiliation, will also be disclosed to people who ask for you by name. You have the right to request that you name not be included in the Bronson Battle Creek 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, Bronson Battle Creek will disclose the patient's death and contact information about funeral arrangements in response to a directory inquiry after the patient's next of kin have been notified.

c. Spiritual Care: Directory information including your religious affiliation will be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. Your name, location and general condition will be disclosed to members of the religious community. It is our policy not to notify your local religious organization, by disclosing your name that you are in Bronson Battle Creek, 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 Bronson Battle Creek. You have a right to request that you name not be given to any member of the clergy.

d. Promotional Communications: Bronson Battle Creek does 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. Bronson Battle Creek does maintain a database of individuals for promotional communications, disease management, health promotion, and fundraising purposes. This database includes individuals to whom Bronson Battle Creek may have sent health improvement materials and news about Bronson Battle Creek previously and also individuals who have donated to Bronson Battle Creek or who have expressed and interest in donating to Bronson Battle Creek or other health-related activities. You may be included in this database. Bronson Battle Creek sends information to the individuals in this database about the programs and services of Bronson Battle Creek. If you wish to be deleted form this database, you may notify the Privacy Official of Bronson Battle Creek.

e. Media Conditions Reports: Bronson Battle Creek 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 and opportunity to agree or object. The following information may then be disclosed: your condition 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: Bronson Battle Creek is not permitted to provide your PHI to any other person or company for marketing to you of any products or services other than Bronson Battle Creek's products or services unless you have signed an authorization.

b. Research: Bronson Battle Creek will 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, Bronson Battle Creek may require that you sign an authorization to allow the researchers to use and 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: Bronson Battle Creek will disclose your PHI for law enforcement purposes, such as responding to a court order or subpoena, identifying a suspect or a missing person, or providing information about a crime victim or criminal conduct.

b. Required by Law: Bronson Battle Creek will disclose PHI about you when required to do so by federal, state or local law. Bronson Battle Creek also will make disclosures for judicial and administrative proceedings such as lawsuits or other disputes in response to a court order or subpoena. Bronson Battle Creek will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violence. Bronson Battle Creek 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. Bronson Battle Creek will make certain disclosures that are required in order to comply with workers' compensation or similar programs.

c. Coroners, Medical Examiners, Funeral Directors: Bronson Battle Creek may release your PHI to a coroner or medical examiner to identify a deceased individual or to identify the cause of death. If necessary, Bronson Battle Creek may also disclose PHI to funeral directors as necessary to carry out their duties.

d. Organ Procurement: Bronson Battle Creek may release PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes.

e. Health or Safety: Bronson Battle Creek will use and disclose PHI to avert a serious threat to health and safety of a person or the public. Bronson Battle Creek uses and discloses PHI to Public Health Agencies for immunizations, communicable diseases, etc. Bronson Battle Creek 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 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 purposes of tracking.

V. Your Health Information Rights

Although we at Bronson Battle Creek must maintain all records concerning your hospitalization and/or treatment by Bronson Battle Creek, you have the following rights concerning your PHI:

a. Right to Inspect and Copy: You have the right to inspect and have copies of your PHI made for you as long as we maintain it except for: information that will be used in a civil, criminal or administrative action or proceeding and where prohibited or protected by law. Bronson Battle Creek 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;
• You are an inmate at a correctional institution and obtaining a copy of the information would risk the health, safety, security, custody or rehabilitation of you or other inmates;
• The disclosure of the information would threaten the safety of any officer, employee or other person at the correctional institution or who is responsible for transporting you;
• You are involved in a clinical research project and Bronson Battle Creek 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.
• Bronson Battle Creek 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; or
• Under other limited circumstances. In these instances, however, Bronson Battle Creek will allow the review of its decision by a health care professional that Bronson Battle Creek has chosen. This person will not have been involved in the original decision to deny your request.
• You agree to pay a reasonable copying charge. You must make your requests to access and copy your PHI in writing to Bronson Battle Creek. Bronson Battle Creek will respond to your request within 30 days of its receipt. If Bronson Battle Creek cannot, Bronson Battle Creek will notify you in writing to explain the delay and the date by which we will act on your request. In any event, Bronson Battle Creek 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 Bronson Battle Creek maintains it. However, Bronson Battle Creek will deny your request for amendment if:

• Bronson Battle Creek 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
• The information is accurate and complete.

If Bronson Battle Creek denies your request for changes in your PHI, Bronson Battle Creek will notify you in writing with the reason for the denial. Bronson Battle Creek will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that Bronson Battle Creek include your request for amendment and the denial any time that Bronson Battle Creek discloses the information that you wanted changed. Bronson Battle Creek may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.

You must make your request for amendment of your PHI in writing to Bronson Battle Creek, including your reason to support the requested amendment. Bronson Battle Creek will respond to your request within 60 days of its receipt. If Bronson Battle Creek cannot, Bronson Battle Creek will notify you in writing to explain the delay and the date by which Bronson Battle Creek will act on your request. In any event, Bronson Battle Creek will act on your request within 90 days of its receipt

c. Right to an Accounting: You have a right to receive an accounting of the disclosures of your PHI that Bronson Battle Creek 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 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 the was one.

You must make your request for an accounting of disclosures of your PHI in writing to Bronson Battle Creek. You must include the time period of the accounting, which will not be longer than 6 years. Bronson Battle Creek will respond to your request within 60 days from its receipt. If Bronson Battle Creek cannot, Bronson Battle Creek will notify you in writing to explain the delay and the date by which Bronson Battle Creek will act on your request. In any event, Bronson Battle Creek will act on your request within 90 days of its receipt.

In any given 12-month period, Bronson Battle Creek will provide you with an accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting will be subject to a reasonable fee in 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 information 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 ask that your name not be used in the waiting room or that information about your expected discharge date not be shared with your family. Bronson Battle Creek will consider your request but is not required to agree to the requested restrictions.

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 Bronson Battle Creek 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.

VI. Complaints

If you believe your privacy rights have been violated, you may file a complaint with Bronson Battle Creek or with the Secretary of the Department of Health and Human Services. To file a complaint with Bronson Battle Creek, please contact the Bronson Battle Creek's Privacy Officer at (269) 245-8017. All complaints must be submitted in writing directly to the Bronson Battle Creek's Privacy Officer. There will be no retaliation for filing a complaint.

VII. Sharing and joint use of your Health Information

In the course of providing care to you and in furtherance of Bronson Battle Creek's mission to improve the health of the community, Bronson Battle Creek will share your PHI with other organizations as described below whom have agreed to abide by the terms described below:

a. Medical Staff: The medical staff and Bronson Battle Creek participate together in an organized health care arrangement to deliver health care to you at Bronson Battle Creek. Both Bronson Battle Creek 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 Bronson Battle Creek. Physicians and allied health care providers are members of Bronson Battle Creek's medical staff and will have access to and use you PHI for treatment, payment and health care operations purposes related to your care within Bronson Battle Creek. Bronson Battle Creek will disclose your PHI to the medical staff for payment, treatment and health care operations.

b. Business Associates: Bronson Battle Creek will use and disclose your PHI to business associates contracted to perform business functions on its behalf including Trinity Health, its parent who performs certain business functions for Bronson Battle Creek. Whenever, an arrangement between Bronson Battle Creek and another company involves the use and disclosure of your PHI, that business associate will be required to keep your information confidential.

c. Membership in Trinity Health: Bronson Battle Creek, 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, and healthcare operations. As a part of Trinity Health, a national Catholic health care system, Bronson Battle Creek 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 you PHI for your treatment, payment to Bronson Battle Creek and/or for the health care operations permitted by HIPAA with respect to our mutual patients.

• Bronson Battle Creek will share your PHI with these organizations for purposes of your treatment, payment, and health care operations by these organizations.

VIII. Additional Information

For further information regarding the issues covered by this Notice of Privacy Practice, please contact: Privacy Official at 300 North Avenue Battle Creek, MI 49016 Phone No. (269) 245-8017.

XI. Changes to this Notice

Bronson Battle Creek will abide by the terms of the Notice currently in effect. Bronson Battle Creek reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. Bronson Battle Creek will provide you with the revised Notice at your first visit following the revision of the Notice.