Effective Date: September 23, 2013
(Format Revised: May 21, 2020)
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
If you have any questions about this notice, please contact our Privacy Officer or the Manager of our Health Information Management Department at the address or telephone number provided at the end of this Notice.
This notice describes our hospital’s practices and that of:
- Any health care professional authorized to enter information into your hospital chart.
- All departments and units of the hospital.
- Any member of a volunteer group we allow to help you while you are in the hospital.
- All employees, staff and other hospital personnel.
- We are required by law to maintain the privacy and security of your medical information, to follow the duties and privacy practices described in this Notice, and to give you a copy of this Notice.
- We will inform you promptly if a breach occurs that may have compromised the privacy or security of your medical information.
- We will not use or disclose your medical information other than as described in this Notice without your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except as described in this Notice. You understand that we are unable to take back any disclosures we have already made with your authorization and that we are required to retain our records of the care that we provided to you.
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
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 professionals who are treating you. 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. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the hospital may be billed to – and payment may be collected from – you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose medical information about you for hospital operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes.
For Health Information Exchange or Personal Health Record Participation. We may participate in one or more health information exchanges (HIEs) through which we electronically share your health information for treatment, payment and healthcare operations with other participants in the HIEs. Additionally, we may make your health information available to you or your personal representatives through an electronic personal health record (PHR). Your participation in HIEs and PHRs is voluntary, and you may opt out of either or both by contacting our Privacy Officer, or the Manager of our Health Information Management Department, at the address or telephone number provided at the end of this Notice.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Fundraising Activities. We may contact you as part of a fundraising effort. You have the right to opt out of receiving such communications by contacting our Privacy Officer, or the Manager of our Health Information Management Department, at the address or telephone number provided at the end of this Notice.
Marketing and Sale of Information. We cannot use or disclose your medical information for marketing purposes without your authorization, except face-to-face communications and promotional gifts of nominal value. We also cannot sell your medical information without your authorization, except under certain limited circumstances that are specifically permissible under law.
Psychotherapy Notes. We may not use or disclose psychotherapy notes without your authorization except in certain limited circumstances: (i) for treatment; (ii) for supervised mental health training programs; (iii) for health oversight activities or certain permitted uses by coroners and medical examiners; (iv) to defend legal actions brought against us; (v) as required by law, and (vi) to prevent or lessen a serious and imminent threat to public health or safety.
Hospital Directory and Individuals Involved in Your Care. We may include certain limited information about you in the hospital directory while you are a patient at the hospital unless you ask us not to. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. This is so your family and friends can visit you in the hospital and generally know how you are doing.
We may also disclose medical information about you to a friend or family member who is involved in your medical care if you consent, or if consent may be reasonably inferred from the circumstances. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital.
We will provide you with an opportunity to object to these disclosures, or to restrict or prohibit some or all of these disclosures. In situations where you are unable to object due to incapacity or an emergency treatment circumstance, our disclosures under this section will be consistent with your prior expressed preference and our professional judgment as to whether the disclosure is in your best interest. We will inform you of these disclosures and provide you with an opportunity to object to future disclosures when it becomes practicable to do so.
School Immunizations. We may disclose medical information about an individual who is a student or prospective student if the individual (or his or her personal representative, if applicable) agrees, and if the disclosure is limited to proof of immunization and if the school is required by law to have such proof prior to admitting the student.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. 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 condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project. For example, to help them look for patients with specific medical needs so long as the medical information they review does not leave the hospital. 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 at the hospital.
De-identified Information and Limited Data Sets. We may use or disclose your medical information in a format that does not directly identify you for the purpose of conducting research, quality assessments, or statistical analysis. We will comply with all applicable laws and regulations if we do so. For example, we may combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed and whether certain new treatments are effective.
As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. We are required to disclose your health information to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance with federal privacy rules.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Worker’s Compensation. We may also release medical information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
- To prevent or control disease, injury or disability
- To report births and deaths
- To report child abuse or neglect
- To report reactions to medication or problems with products
- To notify people of recalls of products they may be using
- 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
- To notify the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose medical information to a health oversight agency 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 healthcare system, government programs and compliance with civil rights laws.
Disaster Relief Efforts. We may disclose your medical information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating with such entities.
Lawsuits and Disputes. We may disclose your medical information in the course of a judicial or administrative proceeding. We will comply with all applicable laws and regulations when making such disclosures.
Law Enforcement. We may release medical information if asked to do so 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;
- About criminal conduct at the hospital; 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.
Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
You have the following rights regarding medical information we maintain about you:
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.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Health Information Management Department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
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 healthcare professional chosen by the hospital 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.
If you request an electronic copy of your medical information, we will provide it in the form and format you request if it is readily producible in that manner; if not, we will provide it in a readable electronic form and format as agreed upon between you and us.
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the hospital.
To request an amendment, your request must be made in writing and submitted to the Health Information Management Department. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for the hospital;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. We will include the disclosures specified by applicable laws and regulations, but will not include those relating to treatment, payment, health care operations, and certain other applicable exclusions (such as those you asked us to make).
To request this list or accounting of disclosures, you must submit your request in writing to the Health Information Management Department. Your request must state a time period which may not be longer than six years prior to the date of your request. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-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 cost is incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare 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 the 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 most requests. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
- We are required to agree to a requested restriction that pertains to disclosures to a health plan about an item or service that you have paid for out-of-pocket in full.
- To request restrictions, you must make your request in writing to the Manager of Health Information Management. 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; and (3) to whom you want the limits to apply, for example, disclosure to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. 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 to the Manager of Health Information Management. 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 Appoint a Personal Representative. You have the right to appoint a personal representative to exercise your rights on your behalf, such as through a valid power of attorney. In some cases, the law gives others the right to act on your behalf, such as when you have a legal guardian.
Right to 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 at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, please contact the Health Information Management Department.
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. If the Privacy Notice is updated, a new Notice will be posted on our website, available in our Health Information Management Department, and given at the time of registration.
You have the right to file a complaint if you feel we have violated your rights. You may do so by contacting our Privacy Officer, or the Manager of our Health Information Management Department at the address or telephone number provided at the end of this Notice. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov. We will not retaliate against you for filing a complaint.