Notice of Privacy Practices Policy
Spectrum Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Spectrum Health does not exclude people or treat them differently because of race, color, national origin, age, disability, sexual identity or sex.
To ensure compliance with applicable law and regulation regarding the creation, maintenance and distribution of Spectrum Health's Joint Notice of Privacy Practices (PDF).
The definitions to the following terms used within this document may be found in the Information Services Glossary of Terms Used in Policies and Procedures (PDF):
- Covered Entity
- Organized Health Care Arrangement (OCHA)
- Protected Health Information (PHI)
Any person in violation of this policy is subject to corrective action, up to and including termination.
PolicyIt is the policy of Spectrum Health to create, maintain and distribute in accordance with applicable law and regulation a Notice of Privacy Practices (“Notice”).
Right to Notice
All Individuals have a right to adequate notice of the uses and disclosures of Protected Health Information that may be made by Spectrum Health, and of the Individual's rights and Spectrum Health's legal duties with respect to Protected Health Information.
Uses and Disclosures in Conformity With the Notice
Spectrum Health may not use or disclose Protected Health Information in a manner inconsistent with its Notice of Privacy Practices.
Revisions to the NoticeSpectrum Health must promptly revise and distribute its Notice whenever there is a material change to the uses or disclosures, the Individual's rights, Spectrum Health's legal duties, or other privacy practices stated in the Notice.
Except when required by law, a material change to any term of the Notice may not be implemented prior to the effective date of the Notice in which such material change is reflected.
Provision of Notice
Spectrum Health must:
- Provide the Notice:
- No later than the date of the first service delivery, including service delivered electronically, to any Individual, after the first effective date of this policy;
- In an emergency treatment situation, as soon as reasonably practicable after the emergency treatment situation.
- Have the Notice available at all offices and other service delivery sites to Individuals to request to take with them;
- Post the Notice in a clear and prominent location where it is reasonable to expect Individuals seeking service from Spectrum Health to be able to read the Notice; and
- Whenever the Notice is revised, make it available upon request on or after the effective date of the revision and promptly provide the Notice to Individuals.
Specific Requirements for Electronic Notice
- Spectrum Health must prominently post its Notice on its website, and make the Notice available electronically through the website.
- Spectrum Health may provide the Notice to an Individual by e-mail, if the Individual agrees to electronic notice, and such agreement has not been withdrawn. If Spectrum Health knows that the e-mail transmission has failed, a paper copy of the Notice must be provided to the Individual. Provision of electronic notice by Spectrum Health will satisfy the provision requirements herein when timely made.
- If the first service delivery to an Individual is delivered electronically, Spectrum Health must provide electronic notice automatically
- The Individual who is the recipient of electronic notice retains the right to obtain a paper copy of the Notice from Spectrum Health upon request.
Joint Notice by Separate Covered Entities
Because Spectrum Health participates in Organized Health Care Arrangements (OHCA) with other Covered Entities, it may comply by a Joint Notice, provided that:
- The Covered Entities participating in the Organized Health Care Arrangement agree to abide by the terms of the Notice with respect to Protected Health Information created or received by said covered entity or by Spectrum Health as part of its participation in the OHCA;
- The Joint Notice meets the content of Notice requirements, except that the statements required may be altered to reflect the fact that the Notice covers more than one Covered Entity;
- Describes with reasonable specificity the Covered Entities, or class of Covered Entities, to which the Joint Notice applies;
- Describes with reasonable specificity the service delivery sites, or classes of service delivery sites, to which the Joint Notice applies;
- If applicable, states that the Covered Entities participating in the OHCA will share Protected Health Information with each other, as necessary to carry out treatment, payment or health care operations relating to the Organized Health Care Arrangement.
- The Covered Entities included in the Joint Notice must provide the Notice to Individuals, in accordance with the applicable provision of Notice specifications in this policy.
- Provision of the Joint Notice to an Individual by any one of the Covered Entities included in the Joint Notice will satisfy the provision requirement herein with respect to all others covered by the Joint Notice.
Spectrum Health must document compliance with the Notice requirements by retaining copies of the Notices issued by Spectrum Health, and if applicable, any written acknowledgments of receipt of the Notice or documentation of good faith efforts to obtain such written acknowledgment in accordance with this policy, for at least six (6) years.
Original Effective Date: 04/14/2003
Revised Date: 05/01/2011, 09/23/2013
Spectrum Health reserves the right to alter, amend, modify or eliminate this policy at any time without prior written notice.References
- HIPAA Regulations 45 CFR §§ 164. 502(i) and 164.520
- Consent (General) for Treatment and Release of Information (PDF)