Privacy Notice




Your health record is the physical property of the Copper Ridge Surgery Center (CRSC). The information contained within the record, however, belongs to you. You have the right to:

A. Ask us for a copy of this notice. Get a paper or electronic copy of this notice at any time by requesting it from the Chief Executive Officer of the surgery center.

B. Get an electronic or paper copy of your medical record. You have the right to obtain a copy of your medical record in the form and format you request as long as we maintain it.

You must make your request in writing to the Chief Executive Officer of the surgery center and CRSC will respond to your request within (30) days of its receipt. We may charge a reasonable cost-based fee.

C. Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete by requesting, in writing, that an amendment be made. We may say “no” to your request, but we’ll tell you why in writing within sixty (60) days.

D. Get a list of those with whom we’ve shared information. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

We will include all the disclosures except for those about treatment, payment and health care operations and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

E. Request confidential communications. You can ask us to contact you in a specific way for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests.

F. Ask us to limit what we use or share. You can ask us not to share certain health information for treatment, payment or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

If you pay for a service out-of-pocket in full, you may request to withhold that information for the purpose of payment or our operations with your health insurer. We will comply with your request unless a law requires us to share that information.

G. Choose someone to act for you. If you have given someone medical power of attorney or is someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure that person has this authority and can act for you before we take any action.


II. Your Choices

For certain health information, you can tell us your choices about what we share. Tell us what you want to do and we will follow your instructions.

A. In these cases, you have both the right and choice to tell us to:

  1. Share information with your family, close friends, or others involved in your care
  2. Share information in a disaster relief situation

B. In these cases, we never share your information unless you give us written permission:

  1. Marketing purposes
  2. Sale of your information
III. Our uses and disclosures

How do we typically use or share your health information?

A. Treatment. We can use your health information and share it with other professionals who are treating you, for example, lab work, x-rays and prescriptions. We will disclose information to people or entities outside of CRSC who will be involved in your medical care after you leave CRSC such as other care providers and/or family members.

If you are an inmate of a correctional institution or under the custody of a law enforcement officer, we will disclose your health information to the correctional institution or officer.

B. Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary; for example: to contact you as a reminder that you have an appointment as CRSC.

C. Bill for your services. CRSC will disclose health information about your for the purposes of determining insurance coverage and eligibility, billing, claims management, medical data processing and reimbursement.

This information may also be released to independent health care providers who were involved in your treatment (for example, anesthesia providers who are not employed by CRSC) so that they may seek payment for caring for you. CRSC may disclose information to collection agencies or subcontractors engaged in obtaining payment for care.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health or research. We have to meet many conditions in the law before we can share your information for these purposes. Uses include:

D. Help with public health and safety issues. We can share health information about you for certain situations such as: preventing disease, helping with product recalls, reporting adverse reactions to medicines, reporting suspected abuse, neglect or domestic violence, preventing or reducing a threat to anyone’s health or safety.

E. Research. We can use or share your information for health research but the Copper Ridge Surgery Center does not engage in such research.

F. Comply with the law. We will share your information if state or federal laws require it, including the Department of Health and Human Services to see that we are complying with federal privacy law.

G. Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.

H. Work with a medical examiner or funeral director. We can share information with these entities when an individual dies.

I. Address workers compensation, law enforcement and other government requests. We can use or share health information about you for workers compensation claims, law enforcement purposes, health oversight agencies for activities authorized by law, special government functions such as military, national security and presidential protective services.

J. Respond to lawsuits and legal actions. We can share information about you to respond to a court or administrative order or in response to a subpoena.

IV. Our Responsibilities

We are required by law to:

  1. Maintain the privacy and security of your protected health information.
  2. Let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  3. Follow the duties and privacy practices described in this notice and give you a copy of it.
  4. Not use or share your information other than as described here unless you tell us we can in writing. You have the right to revoke an authorization at any time, by putting your request in writing and submitting the request to the Medical Records department. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. The revocation, however, will not have any effect on any action taken by CRSC before it received the revocation.

For more information, see:

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 than under HIPAA and when under state law the records are more protected from disclosure than under HIPAA. Certain federal laws also are more stringent than HIPAA. Munson will continue to abide by these more stringent state and federal laws

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

V. Complaints

If you have questions or would like additional information, you may contact LoAnn Vande Leest, Chief Executive Officer, at 231-392-8950.

If you believe your privacy rights have been violated, you can submit a written complaint describing the circumstances surrounding the violation to:

LoAnn Vande Leest
Copper Ridge Surgery Center
4100 Park Forest Drive
Traverse City, MI 49684

You may also register complaints with the state of Michigan through the following:

Michigan Department of Licensing and Regulatory Affairs
Bureau of Community and Health Systems, Health Facility Complaints
P.O. Box 30664
Lansing, MI 48909

Or with the U.S. Department of Health and Human Services for Civil Rights at:

200 Independence Avenue, S.W.
Suite 515F, HHH Building
Washington, D.C. 20201

Hotline: 1-877-696-6775

CRSC assures you that there will be no retaliation for filing a complaint.

"Everyone was friendly from check in to discharge. I am very impressed and pleased. You have a fabulous staff. It couldn't possibly have been a better experience. "
- Claudia
"If procedures are necessary, it is a pleasure having them done at the Surgery Center. All processes have been well thought out and streamlined with the patient in mind. There does not seem to be any unnecessary steps or duplication of effort."
- Gary
"Excellent care --- and my anesthesiologist was very caring about my comfort throughout the surgery."
- Ellen
"Always such a nice experience here when you're having medical procedures done. It's never fun, but I try to be positive about it and the staff and docs are great. Glad to find good care here 'Up North.' "
- Heidi P.
"The staff was great at making us feeling comfortable sending our 3-year old in for surgery. They put our minds at ease and he is recovering great. Thanks! - Grant"
- Grant
"The follow up phone calls both from the surgeon and nurse were very comforting, and appreciated. All in all, a first class operation; thanks for your caring"
- Lee M.
"All of the staff were incredible - particularly the nurses that won over my 4-year old in record time, so that he happily and willingly went back with them for his surgery with no hesitation, and the nursing staff that helped care for him post-op. Truly incredible people!"
- Jennifer