NOTICE OF PRIVACY PRACTICES
Your rights under the Health Insurance Portability & Accountability Act of 1996 (HIPAA)
How Your Medical Information May Be Used and Disclosed & How You Can Get Access To This Information
If you have any questions about this notice, please contact the Facility Privacy Officer.
PLEASE REVIEW CAREFULLY
If you have any questions about this notice,
Please contact the Privacy Officer at 775-8581 or (ext. 8581)
Who Will Follow This Notice: This notice describes the facility's practices and that of:
Our Pledge Regarding Medical Information: We understand that medical information about you and your healthcare is personal. We are committed to protecting medical information about you. A record is created of the care and services you receive at this facility. This record is needed to provide the necessary care and to comply with legal requirements. This notice applies to all of the records of your care generated by the facility. Your personal physician may have different policies or notices regarding the physician's use and disclosure of your medical information in the physician's office or clinic.
This notice will tell about the ways in which the facility may use and disclose medical information about you. Also described are your rights and certain obligations we have regarding the use and disclosure of medical information.
The law requires the facility to:
HOW THE FACILITY MAY USE and DISCLOSE YOUR MEDICAL INFORMATION:
The following categories describe different ways the facility uses and discloses medical information. Each category will be explained. Not every possible use or disclosure will be listed. However, all the different ways the facility is permitted to use and disclose information will fall within one of these categories.
For example: A doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the
healing process. The doctor may need to tell the dietitian about the diabetes so appropriate meals can be arranged. Different departments of the facility may also share medical information about you in order to coordinate your different needs, such as prescriptions, lab work and x-rays. The facility also may disclose medical information about you to people outside the facility who may be involved in your medical care after you leave the facility, such as family members, home health agencies, or others used to provide services that are part of your care.
For example: The health plan or insurance company may need information about the care you received from the facility so they can provide payment for the surgery. Information may also be given to someone who helps pay for your care. Your
health plan or insurance company may also need information about a treatment you are going to receive to obtain prior approval or to determine whether they will cover the treatment.
For example: Your medical information may be:
1. Reviewed to evaluate the treatment and services performed by our staff in caring for you.
2. Combined with that of other facility patients to decide what additional services the facility should offer, what services are not needed, and whether certain new treatments are effective.
3. Disclosed to doctors, nurses, technicians, and other agents of the facility for review and learning purposes.
4. Disclosed to healthcare students, interns and residents.
5. Combined with information from other facilities to compare how we are doing and see where we can improve the care and services offered. Information that identifies you in this set of medical information may be removed so others may use it to study health care and health care delivery without knowing who the specific patients are.
This information may include your name, address, and admission date.
For example: A research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same conditions. All research projects, however, are subject to a special
approval process. This process evaluates a proposed research project and its use of medical information, balancing the
research needs with the patients' need for privacy of their medical information. Your medical information may be disclosed to people preparing to conduct a research project; for example, helping them look for patients with specific medical needs, so long as the medical information they review does not leave the facility. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.
1. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, your medical information will be
disclosed in response to a court or administration order, subpoena, discovery request, or other lawful process by someone else involved in the dispute when we are legally required to respond.
2. Law Enforcement. Your medical information will be released if requested by a law enforcement official:
§ In response to a court order. subpoena, warrant, summons or similar process;
§ To identify or locate a suspect, fugitive, material witness, or missing person;
§ About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
§ About a death we believe may be the result of criminal conduct; and
§ In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
3. National Security and Intelligence Activities. Your medical information will be released to authorized
federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
4. Protective Services for the President and Others. Your medical information may be disclosed to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of
state or conduct special investigations.
5. To Alert a Serious Threat to Health or Safety. Your medical information may be used and disclosed when necessary to prevent a serious threat to your health and safety and that of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
6. Health Oversight Activities. Your medical information may be disclosed to a health oversight facility for
activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
necessary to facilitate organ or tissue donation and transplantation.
and to the Food and Drug Administration, if applicable. This information may be used to locate you should there be a need with regard to such medical device(s).
1. To prevent or control disease, injury or disability;
2. To report births and deaths;
3. To report child abuse or neglect
4. To report reactions to medications or problems with products;
5. To notify people of recalls of products they may be using;
6. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
7. To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
1. For the institution to provide you with health care;
2. To protect the health and safety of you and others; and
3. For the safety and security of the correctional institution.
disclose your medical information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use o disclose your medical information for the reasons covered in your written authorization. You
understand that we are unable to take back any disclosures already made with your permission, and that we are required to retain our records of the care that the facility provided to you.
ADDITIONAL INFORMATION CONCERNING THIS NOTICE:
current copy of the notice with the effective date. In addition, each time you are admitted to the facility for care/services, as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with the facility or with the Secretary of the Department of Health and Human Services. To file a complaint with the facility, contact the Facility Privacy Officer. All complaints must be submitted in writing.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding medical information the facility maintains about you:
** NOTE: All Requests Must Be Submitted in Writing to the Facility Medical Records Department.
To inspect and copy medical information or to receive an electronic copy of the medical information that may be used to make decisions about you, you must submit a written request
If you request a paper copy of the information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request.
If the facility uses or maintains an electronic health record with respect to your medical information, you have the right to
obtain an electronic copy of the information if you so choose.
1. You may direct the facility to transmit the copy to another entity or person that you designate provided the choice is clear, conspicuous, and specific.
2. The facility may charge a fee equal to its labor cost in providing the electronic copy.
We may deny your request to inspect and copy in some limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional, other than the person who denied your request, will be chosen by the facility to review your request and the denial. The facility will comply with the outcome of the review.
1. A licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person.
2. The protected health information makes reference to another person (unless such other person is a health
care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person.
3. The request for access is made by the individual's personal representative, and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such
personal representative is reasonably likely to cause substantial harm to the individual or another person.
To request an amendment, your must submit a written request. You must also provide a reason that supports your request. Your request for an amendment may be denied if:
1. Your request is not in writing or does not include a reason to support the request;
2. The medical information was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
3. The medical information is not part of the medical information kept by or for the facility;
4. The medical information is not part of the information you would be permitted to inspect and copy; or
5. The medical information is accurate and complete.
To request this list or accounting of disclosures:
1. You must submit your request in writing.
2. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003.
3. Your request should indicate in what form you want the list (for example. on paper, electronically).
The first list you request within a12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
To request restrictions, you must make your request in writing. In your request, you must tell us:
1. What information you want to limit;
2. Whether you want to limit our use, disclosure or both;
3. To whom you want the limits to apply (for example, disclosures to your spouse).
You also have a right to request that a health care item or service not be disclosed to your health plan for payment purposes or health care operations. We are required to honor your request if the health care item or service is paid out of pocket and in full. This restriction does not apply to use or disclosure of your health information related to your medical treatment.
For example: You can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a copy of this notice. You may ask us to give you a copy at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the hospital. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, a copy of the current notice in effect will be offered to you.
If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, contact the Privacy Officer. All complaints must be submitted in writing.
You will not be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with
your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.