HIPAA NOTICE OF PRIVACY PRACTICES
For Your Protection
This notice describes how medical information about
you may be used and disclosed and how you can get access to this information.
Please review carefully.
Each time you visit a hospital/long term care facility,
healthcare provider, or other healthcare professional,
a record of your visit is made. Typically, this record contains your symptoms,
examination and test results, diagnoses, treatment, and plan for future care or
treatment, and billing related information. This notice applies to all the
records of your care generated by the hospital/long term care facility whether
made by hospital/long term care facility personnel, agents of the hospital/long
term care facility, or your personal provider. If your personal provider is
from a clinic other then CliniCare, they may have different policies or notices
regarding the use and disclosure of the medical information created on you in
their office or clinic.
Our
Responsibilities
We are required by law to maintain the privacy of your
health information and provide you a description of our privacy practices. We
will abide by the terms of this notice and notify you if we cannot agree to a
requested restriction. We will accommodate reasonable requests you may have to
communicate health information by alternative means or at alternative
locations.
Uses
and Disclosures
How we may use and disclose medical information
about you.
The following categories describe examples of the way we
use and disclose medical information:
For
treatment:
We may use medical information about you to provide you treatment or
services. We may disclose medical
information about you to healthcare providers, nurses, technicians, medical
students, or other hospital/long term care personnel who are involved in taking
care of you at PCMH/WWM. For example: a
provider treating you for an injury may need to know if you have diabetes,
because diabetes may slow the healing process, or if your provider orders
Physical Therapy, the nursing staff will need to discuss your care and
treatment with the Physical Therapist.
Different departments of PCMH/WWM
also may share medical information about you in order to coordinate the
different things you may need, such as prescriptions, lab work, meals, and
x-rays.
We may also provide your
current provider or a subsequent healthcare provider with copies of various
reports that would assist him or her in treating you once you are discharged
from PCMH/WWM.
For Payment:
We
may use and disclose medical information about your treatment and services to
bill and collect payment from you, your insurance company, or a third party
payer. For example, we may need to give your insurance company information
about your surgery so they will pay us or reimburse you for the treatment. We
may also tell your health plan about treatment you are going to receive to
determine whether your plan will cover it.
For Health Care
Operations: Members of the medical staff and/or service
improvement team may use information in your health record to assess the care
and outcomes in your case and others like it.
The results will then be used to continually improve the quality of care
for all patients/residents we serve. For
example, we may combine medical information about many patients/residents to
evaluate the need for new services, treatment, or equipment. We may disclose information to healthcare
providers, nurses, and other students for educational purposes.
We may also use and
disclose medical information:
 |
To business associates we have
contracted with to perform the agreed upon service and billing for it;
|
|
To remind you that you have an
appointment for medical care; |
|
To assess your satisfaction with our
services; |
|
To tell you about possible treatment
alternatives; |
|
To tell you about health-related
benefits or services; |
|
To contact you as part of fund raising
efforts; |
|
As required by state or federal law; |
|
For Population based activities
relating to improving health or reducing health care costs; |
|
For conducting training programs and
reviewing competence of health care professionals. |
Business Associates:
There are some services provided in our organization through contracts with
business associates. Examples may
include professional services in the emergency department, radiology, or
certain outside laboratories. When these
services are contracted, we may disclose your health information to our
business associate so that they can perform the job we’ve asked them to do and
bill you or your third party for services rendered. To protect your health information, however,
we require the business associate to appropriately safeguard your information.
Directory:
We may include certain limited information about you in the Facility directory
while you are here. The information may include your name, location in the
facility, your general condition (e.g.
fair, stable, etc,) and your religious affiliation. This information may be
provided to members of the clergy and, except for religious affiliation, to other
people who ask for you by name. If you
would like to opt out of being in the Facility directory, please request the
Opt Out Form
from the admission staff or Facility Privacy
Officer.
Individuals Involved in
Your Care or Payment for Your Care:
We may release medical
information about you to a friend or family member who is involved in your
medical care or who helps pay for your care. In addition, we may disclose
medical information about you to an entity assisting in a disaster relief
effort so that your family can be notified about your condition, status, and
location.
Research:
We may disclose information to researchers when an institutional review board
has reviewed the research proposal and established protocols to ensure the
privacy of your health information has approved their research.
Future Communications:
We may communicate to you via newsletters, mail outs, or other means regarding
treatment options, health related information, disease-management programs,
wellness programs, or other community based initiatives or activities our
facility is participating in.
Organized Health Care
Arrangement
Information will be shared as necessary to carry out treatment, payment,
and health care operations. Healthcare
providers may have access to protected health information in their offices to
assist in reviewing past treatment as it may affect treatment at the time.
Affiliated Covered
Entity: Protected health information will be made
available to your healthcare provider as necessary to carry out treatment,
payment, and health care operations.
As Required by Law:
Funeral Directors: We
may disclose health information to funeral directors consistent with applicable
law to carry out their duties.
Coroners: We may
disclose health information to coroners consistent with applicable law to carry
out their duties.
Organ Procurement
Organizations: Consistent with applicable law, we may disclose health
information to organ procurement organizations or other entities engaged in the
procurement, banking, or transplantation of organs for the purpose of tissue
donation and transplant.
Food and Drug Administration
(FDA): We may disclose to the FDA health information relative to adverse
events with respect to food, supplements, product, and product defects or post
marketing surveillance information to enable product recalls, repairs or
replacement.
Workers Compensation: We
may disclose health information to the extent authorized by and to the extent
necessary to comply with laws relating to workers compensation or other similar
programs established by law.
Public Health: As
required by law, we may disclose your health information to public health or
legal authorities charged with preventing or controlling disease, injury, or
disability.
Correctional Institution: Should
you be an inmate of a correctional institution, we may disclose to the
institution or agents thereof, health information necessary for your health,
and the health and safety of other individuals.
Law Enforcement: We may
disclose health information for law enforcement officials. For example, disclosures may be made in
response to a warrant or subpoena or for the purpose of identifying or locating
a suspect, witness or missing persons or to provide information concerning
victims of crimes.
Abuse or
neglect: We may make disclosures to
government authorities concerning abuse, neglect, or domestic violence as required by law.
Your Health
Information Rights
Although your health record is the physical property of
the healthcare facility that compiled it, you have the Right to:
| Inspect and Copy: You have the
right to inspect and copy medical information that may be used to make
decisions about your care. Usually, this
includes medical and billing records, but does not include psychotherapy notes. We may deny your request to inspect and copy
in certain very limited circumstances.
If you are denied access to medical information, you may request that
the denial be reviewed. Another licensed health care professional chosen by the
hospital/nursing home will review your request and the denial. The person conducting the review will not be
the person who denied your request. We
will comply with the outcome of the review. |
| Amend: If you feel that medical information we have about
you is incorrect or incomplete, you may ask us to amend the information.
We will not amend records in the following situations: |
- If we do not have the records you want amended
- If we did not create the records that you want amended
- If we have determined that the records we have are accurate or complete
- The records have been complied in anticipation of a civil, criminal or
administrative action or proceeding
We may deny your request for an amendment and if this occurs, you will be
notified of the reason for the denial. Please note that changes in addresses are
not required in writing.
| An Accounting of Disclosures: You
have the right to request, in writing, information about the times we have
disclosed your personal health information for any purpose other then the following
exceptions: |
- Treatment, payment, or health care operations as
described in the “use and disclosure” section of this notice
- Disclosures that you or your personal representative
have authorized
- Certain other disclosures, such as disclosures for
national security purposes
| Request Restrictions: You have the
right to request a restriction or limitations on the medical information we use
or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on
the medical information we disclose about you to someone who is involved in
your care or payment for your care, like a family member or friend. For example, you could ask that we not use or
disclose information about a surgery you had. We are not required to agree
to your request. If we do agree, we
will comply with your request unless the information is needed to provide you
emergency treatment. |
| Request Confidential Communications:
You have the right to request that we communicate about medical matters in a
certain way or at a certain location.
This can be for one time or all times during your care. We will agree to the request to the extent
that it is reasonable for us to do so.
For example, you can ask that we use an alternative address for billing purposes. We will not request an explanation. |
| A Paper Copy of This Notice: You
have the right to a paper copy of this notice. You may ask us to give you a
copy of this notice at any time. Even if
you have agreed to receive this notice electronically, you are still entitled
to a paper copy of this notice. |
You
may obtain a copy of this notice at our web site. www.cavalierhospital.com
To exercise any
of your rights, please obtain the required forms from the Privacy Officer and
submit your request in writing.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the
revised or changed notice will be effective for information we already have
about you as well as any information we receive in the future. The current notice will be posted in the
hospital/nursing home and include the effective date. When you come to PCMH/WWM for treatment or
health care services you will receive the current privacy practice notice. We
will document the date of receipt. You
can have a copy of the current notice at any time.
COMPLAINTS
If you believe your privacy rights have been violated, or
you disagree with a decision we made about access to your personal health
information you have the right to file a complaint trying to utilize the local
resources by either:
| Calling 701-265-8461 and asking for the Facility
Privacy Officer, Kathleen Brooks; or |
| Filing a written complaint with our privacy
officer: |
Kathleen Brooks, Privacy Officer
Pembina
County Memorial
Hospital
Box 380
Cavalier,
ND
58220;
or
| Notifying
the Secretary of the U. S. Department of
Health and Human Services (HHS). Send your complaint to: |
Medical Privacy Complaint Division
Office of Civil Rights
US.
Department of Health and Human Services
200
Independence Avenue, SW
Room 509F, HHH
Building
Washington,
DC
20201
All complaints must be submitted in writing.
Please be assured that we will not take retaliatory
action against you if you file a complaint about our privacy practices either
with us or HHS.
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 use or 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 you.
If you have any questions about this notice, please
contact the Facility Privacy Officer.
PRIVACY OFFICER:
Name: Kathleen
Brooks
Telephone Number: 701-265-8461
Effective Date: April 14,
2003 Version: 41403
