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Dissemination of Privacy Policy

Policy Title: Dissemination of the Notice of Privacy Practices
Policy No: SP 6.14

Effective Date: April 14, 2003

Revised Date: January 1, 2007, January 1, 2012

Purpose: The federal HIPAA regulations on patient privacy and confidentiality require ProMedica entities to provide notice to patients and the public about how personal health information (“PHI”) may be used and disclosed by the organization.


1. Timing of Provision. The Notice of Privacy Practices must be made available, distributed, and the appropriate signage posted at each ProMedica entity in accordance with this policy on or before April 14, 2003.

2. Availability to the Public. A copy of the Notice of Privacy Practices (“Notice”) must be made available on request to any person who requests it in each separate building where patients receive treatment. A copy of this Notice can be requested by calling the confidential ProMedica Hotline number as listed in Section VI of the Notice, and can be viewed on the ProMedica Web Site at www.Promedica.org.

Individuals have the right to receive a copy of this Notice by e-mail and to request a paper copy. Individuals that cannot read may request that an employee read the Notice to the individual upon appointment.

3. Distribution to Patients. All patients will be offered a copy of the Notice no later than the date of the first service delivery or first treatment encounter on or after April 14, 2003, including service delivered electronically, to such patient. Each ProMedica entity will make a good faith effort to obtain written acknowledgement or receipt of the Notice by having the patient or legally authorized representative sign the Acknowledgement of Notice of Privacy Practices or a similar acknowledgment form. The Notice will remain valid until such time that the notice has been revised.

In an emergency situation, the Notice should be provided and acknowledgment obtained as soon as reasonably practicable after the emergency situation.

When the first treatment encounter for a direct treatment relationship with the patient is over the telephone, the Notice will be forwarded to the individual that day unless the first face-to-face encounter with the patient will occur shortly thereafter. The notice may be forwarded via mail, fax, or e-mail and documentation of that fact shall be maintained for a period of six years. The written acknowledgment will be obtained at the first face-to-face encounter with the patient or earlier in accordance with individual ProMedica entity policy.

Scheduling an appointment is not considered a treatment encounter. As such, the Notice will be provided to the patient at the time the individual arrives at the ProMedica entity for his or her appointment.

If acknowledgment of the Notice cannot be obtained, the good faith efforts to obtain the acknowledgement and the reasons why the acknowledgment was not obtained must be documented on the Acknowledgement of Notice of Privacy Practices form or similar acknowledgment form and retained in the medical record.

4. Inmates. When the patient is an inmate in a correctional facility, provision of the Notice and the attempt to obtain acknowledgment of receipt of the Notice is not required.

5. Signage. Each ProMedica entity is required to post the Notice in all buildings where patients receive treatment. Notice signage for all ProMedica entities is developed and obtained through ProMedica Public Relations.

6. Email Delivery of Notice. The Notice may be provided to a patient by e-mail, if the patient agrees to electronic notice. An electronic acknowledgment from the patient via e-mail will be considered written acknowledgment of receipt. Such e-mail message will be printed and retained in the medical record. If it is known that the e-mail transmission failed, a paper copy of the Notice must be provided to the patient.

7. Website Posting. A copy of the most recent Notice will be posted prominently on the ProMedica website, for each individual ProMedica entity.

8. Revisions to the Notice. ProMedica reserves the right to change its Notice and privacy policies at any time. Any changes will apply to all protected health information. If any changes are made to ProMedica privacy policies, the Notice will be changed, if applicable, and a new Notice will be posted on the web.

9. Record Retention. The individual Privacy Officer at each entity shall retain all versions of the Notice, i.e., the original and all subsequent revised Notices. Copies of the Notices shall be retained for six years.