Notice of Privacy Practices
for Northeast Michigan Community Service Agency, Inc
2375 Gordon Rd ~ Alpena MI 49707 ~ Phone:
989-356-3474 ~ Fax: 989-354-5909 ~ Website: www.nemcsa.org
This
notice describes how medical and other personal information about you may be
used and disclosed by Northeast Michigan Community Service Agency, Inc.
(NEMCSA), and how you can get access to this information. Please review it carefully.
Protecting
the privacy of your medical and other personal information is a responsibility
we take very seriously. We understand
that this information is personal and it is important to you that we keep it
confidential. NEMCSA is committed to
the practices and procedures we have established to protect and keep
confidential the information we obtain from you.
This
notice covers not only NEMCSA, but all departments and units of NEMCSA to the
extent that these departments offer health care or other services; any member
of a volunteer group that assists individuals receiving health care or other
services; and all employees, staff, and other NEMCSA personnel involved in
health care services, or other services, in relation to any personally
identifiable information.
Treatment: We use your information to coordinate health care and related
services. It will also be used to
consult or refer between one or more of your providers. For example, if you are participating in the
Care Management Program, we may disclose to your physician what services you
are receiving.
Payment: Generally, we use and disclose information about your
health so we can administer claims, which includes reimbursing incurred
expenses for treatment and services you receive from a health care provider. For example, we may disclose to your doctor
whether you are eligible for Medicaid coverage.
Health
Care Operations: We use and disclose information
about you for quality assessment and improvement, insurance activities, case
management, legal services, and auditing functions. These uses and disclosures are necessary to make sure our
participants are receiving quality services.
For example, we may use information about you to refer you to other
programs for beneficial services and for program auditing purposes.
Informational
Purposes: NEMCSA may use your personal
information to give you helpful information such as program benefit updates and
consumer protection information. We may
also use your information to contact you for appointment reminders.
Public
Health Risks: As required by law, we may
disclose information about you to public health authorities that receive
information to: prevent or control disease, injury, or disability; report
births and deaths; report child abuse or neglect; and notify a person who may
be at risk for contracting or spreading a disease or condition.
Oversight
Activities: We may disclose information about you to an
agency for activities authorized by law.
Examples of these oversight activities include: audits, investigation,
and inspections. These activities are
necessary for the government to monitor the health care system, government
programs, and entities subject to civil rights laws.
Laws
and Disputes: If you are involved in a
lawsuit or dispute, we may disclose information about you in response to a
court or administrative order. We may
also disclose this information in response to a subpoena or other lawful
process by someone else involved in the dispute. We will make reasonable attempts to tell you about the request.
Law
Enforcement: We may release information
about you if asked to do so by a law enforcement official in response to a
court order, subpoena, warrant, summons or similar process. We may also release information about you to
law enforcement or other governmental authorities to protect us against fraud
or other illegal activities.
Coroners,
Medical Examiners, and Funeral Directors:
We
may release information about you to a coroner or medical examiner. We may also release information about you to
funeral directors as necessary to carry out their duties.
Research: Under certain circumstances, we may use information
about you for program research purposes subject to conditions.
To
Avert a Serious Threat to Health or Safety:
Although
it is not our practice, we may use and disclose information about you when
necessary to help prevent a serious threat to the health and safety of you or
others. Any disclosure, however, would
only be to someone able to help prevent the threat.
Military
and Veterans: If you are a member of the
armed forces, we may release information about you as required by military
command authorities.
Your
Rights Regarding Your Personal Information (Including Health Information): You have the following rights regarding the
information we maintain about you, who you may exercise by submitting a request
in writing to the NEMCSA program you are working with, or with the NEMCSA Main
Office, 2375 Gordon Rd, Alpena, MI
49707.
Right
to Revoke Authorization: You may revoke your
authorization that allows us to use or disclose personal information that is
not otherwise covered by this notice, or allowed under state or federal
law. Any request to revoke should be in
writing and may be made at any time, except to the extent that we have taken
action in reliance on your written authorization. You understand that we are unable to take back any disclosures
that have already been made with your authorization, and that we may retain documents
that may contain information about you.
Right
to Request Restrictions: You have a right to request a
restriction on the information about you that we disclose for treatment,
payment, or health care operations. You
also have the right to request a limit on the information we disclose about you
to someone who in involved in your care or the payment of your care, like a
family member. In your request you must
tell us: the information you want to
limit; whether you want to limit our use, disclosure, or both; and to whom you
want the limits to apply (for example, disclosures to your spouse). We are not required to agree to your
requested restriction or limitation.
Right
to Inspect and Copy: You have a right to inspect
and copy personal information that we maintain about you for as long as the
information is on file with NEMCSA. If
you request a copy of the information, we may charge a cost-based fee for the
copying, mailing, and other supplies.
Inspections and copies will be provided within 30 days if the
information is maintained on site or within 60 days if it is maintained
offsite. You or your representative
will be required to make a written request to the program you are working with
or with the NEMCSA Main Office. If you
are denied access to your information, you may request that the denial be
reviewed.
Right
to Amend: If you believe the information
we have about you is incorrect or incomplete, you may ask us to amend the
information. You must provide a reason
that supports you request. You have the
right to request an amendment for as long as the information is kept by
us. We may deny your request if it is
not in writing or does not include a reason to support the request. We may also deny your request if the
information was not created by us, is accurate or complete as is, or is not
part of the health information you would by permitted to inspect or copy.
Right
to Request an Accounting: You have the right to receive
an accounting of certain disclosures of information about you that we made, if
any. This right applies to disclosures
for purposes other than for treatment, payment, health care operations, or as
otherwise permitted or required by law.
You have a right to receive specific information about any disclosures
that occur after April 13, 2003. The
right to receive this information is subject to certain exceptions,
restrictions, and limitations. The
first disclosure list you request within a 12-month period is free. For any additional requests, we may charge
you for the cost of providing the list.
Right
to a Copy of this Notice: You have the right to obtain a
copy of this notice at any time.
Other
Duties Regarding Personal Information (Including Health Information) About
You: We are required by law to: Maintain the privacy of your personal
information; provide you with notice of our legal duties and health information
privacy practices; and abide by the terms of this notice. NEMCSA will make reasonable efforts to not
use, disclose, or request more than the minimum amount of information necessary
to accomplish the intended purpose.
Changes
to This Notice: NEMCSA reserves the right to
change its privacy practices and to apply the changes to any personal
information received or maintained by NEMCSA prior to that date. If a privacy practice is changed, a revised
version will be available at www.nemcsa.org.
To
File a Complaint: If you believe that your
privacy rights have been violated, you may complain to NEMCSA in care of the
following office: Privacy Officer, 2375
Gordon Rd., Alpena, MI 49707; (989)
356-3474.
You
may also file a complaint with the Secretary of the U.S. Dept. of Health and
Human Services, Hubert H. Humphrey Building, 200 Independence Avenue S.W.,
Washington, D.C. 20201
NEMCSA
will not retaliate against you for filing a complaint.
This
notice was published and became effective on April 14, 2003.
The
Michigan Sate Homeless Management Information System (MSHMIS) was developed to
meet a data collection requirement made by the U.S. Congress to the Dept.
of Housing and Urban Development (HUD)
in order to get a more accurate count of individuals who are homeless and to
identify the need for services by those individuals. NEMCSA works with the State of Michigan in meeting this need and,
therefore, participates in the Michigan Coalition Against Homelessness, which
administers the MSHMIS database.
With
your permission, we share information with other agencies that also use the
MSHMIS to better understand the number of individuals who need services from
more than one agency. This also helps
us make referrals more easily and enables us to develop more efficient and new
programs. We collect information only
when appropriate to provide services, manage our organization or as required by
law. Your record will only be shard if
you give your permission to do so. You
have the right to request that your name be entered in the system as
“anonymous”. You cannot and will not be
denied services that you would otherwise qualify for if you choose not to share
information.
Please
note that even if you do not want to share your information with other agencies
or have your actual name entered into the system, we must still report some
information to the central data collection system. There are provisions to protect your name and privacy.
If
you have any questions regarding the MSHMIS, please contact the NEMCSA Client
Services Dept. at (989) 471-3277. If
you have questions regarding NEMCSA’s privacy practices, contact the agency’s
Privacy Officer at (989) 356-3474.
Addendum
dated 11-11-2005
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Acknowledgement
Receipt
I hereby acknowledge that I
received a copy of Northeast Michigan Community Service Agency, Inc.’s Notice
of Privacy Practices, and that I have had an opportunity to discuss my concerns
or questions about the privacy of my information. I also understand that any changes to the notice will be
available at www.nemcsa.org.
_______________________________________________________ _________________________________________________
Signature Date