THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY:
This notice takes effect on 09-01-09 and remains in effect until we replace it.
1. OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at this organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and
disclosure of medical information.
2. OUR LEGAL DUTY
The Law requires us to:
1. Keep your medical information private.
2. Give you this notice describing our legal duties, privacy practices and your rights regarding your medical information.
3. Follow the terms of the notice that is now in effect.
We Have the Right to:
1. Change our privacy practices and the terms of this notice at any time, provided that the changes are reasonable.
2. Make the changes in our privacy practice and the new terms of our notice effective for all medical
information that we keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before we make an important change in our privacy practices, we will change this notice and make the
new notice available upon request.
3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.
FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other people who are taking care of you. We may also share medical information about you to other healthcare providers to assist them in treating you.
FOR PAYMENT: We may use and disclose your medical information for payment purposes.
FOR HEALTHCARE OPERATIONS: We may use and disclose your medical information for our healthcare operations. This might include measuring and improving quality, evaluation the performance of an employee, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment and healthcare operations, we may use and disclose medical information for the following purposes.
Facility Directory: Unless you notify us that you object, the following medical information about you will be placed in our facilities’ directories: your name, your location in our facility, your condition, described in general terms; your religious affiliation, if any. We may disclose this information to members of the clergy or, except for your religious affiliation, to others who contact us and ask for information about you by name.
Notification: Medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your healthcare, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you.
Disaster Relief: Medical information with a public or private organization or person who can legally assist in disaster relief efforts.
Fundraising: We may provide medical information to one of our affiliated fundraising foundations to contact you for fundraising purposes. We will limit our use and sharing to information that describes you in general, not personal, terms and the dates of your healthcare. In any fundraising materials, we will provide you a description of how you may choose not to
receive future fundraising communications.
Research in Limited Circumstances: Medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.
Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the medical information of a person who has died with the coroner, medical examiner, funeral director, or an organ procurement organization.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim, or missing person. We may share the medical information of an inmate or other personal in lawful custody with a law enforcement official or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect, we may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to tract products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
Victims of Abuse, Neglect or Domestic Violence: We may disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence, or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety to the health or safety of others. We may share medical information when necessary to help law enforcement official capture a person who has admitted to being part of a crime or has escaped for legal custody.
Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.
Health Oversight Activities: We may disclosed medical information to an agency providing health oversight for oversight activities authorized by law, including audits, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or to other authorized activities.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include, reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
4. YOUR INDIVIDUAL RIGHTS
You Have a Right To:
1. Look at or get copies of your medical information. You may request that we provide copies in a format
other than photocopies. We will use the format you request unless it is not practical for us to do so. You
must make your request in writing. You may get the form to request access by using the contact
information listed at the end of this notice. You may also request access by sending a letter to the contact
listed at the end of this notice. If you request copies we will charge you $2.00 for each page, and postage
if you want the copies mailed to you. Contact us using the information listed at the end of this notice for
a full explanation of our fee structure
2. Receive a list of all the times we or our business associates shared your medical information for purposes
other than treatment, payment and healthcare operations and other specified exceptions.
3. Request that we place additional restriction on our use or disclosure of your medical information.
We are not required to agree to these additional restrictions, but if we do will, we will abide by our
Agreement (except in the case of an emergency).
4. Request that we communicate with you about your medical information by different means or to
different locations. You request that we communicate you medical information to you by different
means or at different locations must be made in writing to the contract person listed at the end of this
5. Request that we change you medical information. We may deny your request if we did not create the
information you want changed or for certain other reasons. If we deny your request, we will provide
you a written explanation. You may respond with a statement of disagreement that will be added to the
information you wanted changed. If we accept you request to change the information, we will make
reasonable efforts to tell others, including people you name, of the change and to include the changes
in any future sharing of that information.
6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to
obtain a paper copy by making a request in writing to the Privacy Officer at your office.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice or if you think that we may have violated your rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.