Medical Assisted Treatment (MAT) Program Notice of Privacy Practices
This Notice of Privacy Practices describes the privacy practices of the Medication Assisted Treatment Program (MAT) at MyMichigan Medical Center Sault.
Effective Date: March 1, 2021
MAT is what is known as a "Part 2 Program" under Federal law, and this notice is intended to comply with our obligations under state and federal law to describe how medical information about you acquired or maintained by the program may be used and disclosed and how you can get access to this information. Please review it carefully.
Our Privacy and Confidentiality Obligations
- We are required by federal and state laws to maintain the privacy and confidentiality information about your health, health care, and payment for services related to your health (known as “protected health information” or “PHI”).
- We are required to inform you of our legal duties and privacy practices with respect to your PHI in a notice like this. This Notice describes the ways we may share your past, present and future PHI.
- Federal law, and specifically 42 USC 42 290dd-2 and the related federal regulations, known as 42 CFR Part 2, as well as the Michigan Mental Health Code, provide significant protections against use and disclosure of your PHI when you are applying for or receiving services for substance use disorders.
- The HIPAA Privacy Regulations (45 CFR Parts 160 and 164) also protect your PHI, whether or not you are applying for or receiving services for substance use disorders. Generally, if you are not applying for or receiving services for substance use disorders, the way we may use and disclose information is broader.
- Generally, there are very limited circumstances under which we may use your substance use disorders PHI without your consent. For example, if you are applying for or receiving services for substance use disorders, we cannot acknowledge to a person outside our organization that you attend our program or disclose any information identifying you as an individual seeking treatment, except under circumstances that are listed in this Notice. And except where you specifically authorize us to do so, we may not disclose your Part 2 PHI to law enforcement or any court or other state or federal governmental agency.
Understanding PHI
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. This record may contain your health history, current symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This record and other documentation created by us about you as a result of your participation in MAT programming, including billing information, contains what the law refers to as Protected Health Information (PHI) subject to the strict confidentiality rules established in the privacy laws cited above.
Uses and Disclosures WITH your Authorization
- We may use or disclose your PHI when you give your authorization to do so on a form that specifically meets the requirements of applicable laws and regulations.
- A court with appropriate jurisdiction or other authorized third party may request or compel you to sign an authorization, at any time during or after receiving treatment services from MAT. We may disclose your PHI pursuant to such a document, and that is considered a use or disclosure “with” your authorization.
- Your consent is required if we are requested to disclose your PHI to those individuals within the criminal justice system who have made participation in our program a condition of those proceedings, such as your sentence or parole or release from custody.
- We may disclose your PHI when authorized by your authorized representatives, such as a Personal Representative, Guardian, or pursuant to a healthcare power of attorney, or by such other person authorized by applicable state law as permitted by 42 CFR Part 2. That is considered a use or disclosure “with” your authorization.
- Your consent is required before we can use or disclose your PHI for payment purposes. For example, you must authorize us to disclose PHI to your health insurer or other third-party payor.
- Your consent is required before we can use or disclose your MAT PHI for treatment purposes outside of MAT with other health care providers involved in your care. Note that we reserve the right to terminate your participation in our program if we consider disclosure necessary and you refuse to consent to such disclosure.
Uses and Disclosures WITHOUT your Authorization
Even when you have not given your authorization, we may use and disclose your PHI under the circumstances listed below.
- Treatment: we may use or disclose your PHI for treatment purposes, including assessment, diagnosis, treatment, discharge planning, etc., within the MAT program. For example, our providers may disclose your PHI freely within MAT to coordinate your treatment or discuss treatment alternatives or other health-related benefits and services that are necessary or may be of interest to you.
- Medical Emergencies: we may disclose your PHI to medical personnel to the extent necessary to meet a bona fide medical emergency.
- Mandatory Reporting: we may disclose your PHI where mandatory under Michigan law, including for example the reporting of child and elder abuse or neglect.
- Judicial and Administrative Proceedings: we may disclose your PHI in response to a court order that meets the requirements of federal regulations, 42 CFR Part 2 concerning Confidentiality of Alcohol and Drug Abuse Patient Records.
- Duty to Warn: where MAT learns that a patient has made a specific threat of serious physical harm to another specific person or the public, and disclosure is otherwise allowed or required by law, we will carefully consider appropriate options that would permit disclosure.
- Research, Financial Audit, and Program Evaluation Activities: we may disclose your PHI, but only after it has been de-identified, for research purposes, for purposes of certain audits, and in internal activities designed to improve the quality and effectiveness of the care we provide in this program.
- Required by law: we may disclose your PHI as required by other state or federal laws not specifically mentioned in this Notice. For example, we may be allowed to disclose your PHI to the extent it relates to a patient’s commission of a crime on our premises or against personnel of our program. We may be allowed to disclose PHI relating to, for example, the cause of death under state laws require the collection of death or other vital statistics or public health statistics. We may be required to disclose your PHI to the United States Department of Health and Human Services or the U.S. Attorney’s Office when requested to enforce the privacy laws and ensure organizational compliance.
Your Individual Rights
- Right to Receive Confidential Communications: normally we will communicate with you through the phone number and/or address you provide. You may request, and we will accommodate, any reasonable, written request for you to receive your PHI by alternative means of communication.
- If you are a minor:
- Generally, a parent or other legally responsible person (such as a Guardian) is entitled to access the PHI of a minor child, including substance use disorder PHI. If someone other than a parent is legally responsible for the minor, the parent may be denied access to the patient’s PHI.
- Michigan law expressly allows minors to obtain substance use disorder treatment without the knowledge or consent of a parent or other legally responsible person (such as a Guardian). In that case, the patient’s PHI will be kept confidential unless the clinician feels the minor is at risk or disclosure is required for medical reasons. In these circumstances, where consent is required for disclosure, only the minor may give written consent for disclosure. This includes disclosure to the legally responsible person for the purpose of obtaining financial reimbursement. We may however refuse to provide treatment if the minor refuses to consent to disclosures necessary to obtain reimbursement, unless Michigan law otherwise requires us to furnish the service irrespective of the patient’s ability to pay.
- Where Michigan law requires consent of a legally responsible person for the minor to obtain treatment for a substance use disorder, any consent for disclosure of PHI must be given by both the minor and legally responsible person. Specifically, the fact that a minor is seeking treatment may be communicated to the legally responsible person only if the minor has given written consent to the disclosure or the minor lacks the capacity to make a rational choice regarding such consent (as defined by 42 CFR 2.14(c)).
- Right to revoke or restrict authorized disclosures: You may rescind/revoke authorizations you have executed or given us, in whole or in part, at any time. If you are currently receiving care and wish to rescind/revoke an authorization, you simply need to request this from us, preferably in writing, identifying specifically what information you wish to restrict. After you are discharged from the Program, you will need to send a written statement to the attention of the Privacy Officer. You may request restrictions on our use and disclosure of your PHI for treatment, payment, and health care operations. While we will consider requests for additional restrictions, we are not required to agree to a requested restriction. For example, at your request, you may ask that we not disclose your PHI to your health plan if the disclosure is for payment of a health care item or service for which you have paid MAT out of pocket in full. And please note, if you are currently receiving services from MAT, depending on what restrictions you place on our use or disclosure of your PHI, we may no longer be able to serve you.
- Right to Inspect and Copy your PHI: you may request access, inspect, and obtain a copy of your MAT records and billing records. Under limited circumstances, we may deny you access to a portion of your records. If you are denied access to a record, you may ask that the denial be reviewed, and we will have it reviewed by another provider within our program. All requests for access to your record must be in writing. If you request copies of your records, be aware we have a right to charge for each page copied. MAT must receive payment in full before the copies of your records are given to you.
- Right to amend your Records: you have the right to request that we amend your PHI as documented in your MAT medical or billing records if you believe that it is incorrect or incomplete. Your request must be in writing and include an explanation supporting the requested amendment. Under certain circumstances, MAT has the right to deny your request to amend your records and will notify you of this denial as provided in the HIPAA regulations. If your requested amendment to your records is accepted, a copy of your amendment will become a permanent part of the medical record. When we “amend” a record, we may append information to the original record, as opposed to physically removing or changing the original record. If your requested amendment is denied, you will be informed of your right to have a brief statement of disagreement placed in your medical records. Requests for record amendments should be directed to Health Information Management Department.
- Right to Receive Accounting of Disclosures: upon request, you may obtain a detailed list of when and to whom MAT has disclosed your PHI, for up to the last six years. If you request an accounting more than once during a twelve month period, there will be a charge.
- Right to Receive Notification of Breach: you will be notified in the event we discover a breach has occurred such that your PHI or confidentiality may have been compromised. A risk analysis will be conducted to determine the probability that PHI has been compromised. Notification will be made no more than 60 days after the discovery of the breach, unless it is determined by a law enforcement agency that the notification should be delayed.
- Right to Receive Copy of this Notice: You have a right to receive a copy of this Notice. From time to time, we may change the terms of this Notice. The effective date of this Notice is indicated in the “footer” to this document. You may obtain a copy of the currently effective Notice at any time by contacting the Privacy Officer at (989) 839-3255 or privacy@mymichigan.org.
- For Further Information and/or Complaints: if you require further information about your privacy and confidentiality rights, you may contact the Privacy Officer at (989) 839-3255 or privacy@mymichigan.org. You may call this number if you are concerned in any way that we have violated your privacy rights, if you disagree with a decision that we made about access to your PHI, or if you wish to complain about our breach notification processes. You may also file a written complaint with the Secretary of the United States Department of Health and Human Services. We will not retaliate against in any way you if you file a complaint. Violation of federal law and regulations on Confidentiality of Alcohol and Drug Abuse Patient Records is a crime and suspected violations of 42 CFR Part 2 may be reported to the United States Attorney in the Western District of Michigan, Northern Division, located in Marquette, Michigan.