Notice of Privacy Practices
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.
I. Who We Are
This Notice describes the privacy practices of Shoshone Medical Center. It also applies to Shoshone Medical Center’s Medical Staff and other contracted allied health professionals when providing health care services on your behalf at Shoshone Medical Center.
II. Our Privacy Obligations
We are required by law to maintain the privacy of your medical and health information (“Protected Health Information”) and to provide you with this Notice of our legal duties and privacy practices with respect to Protected Health Information. When we use or disclose Protected Health Information, we are required to abide by the terms of this Notice.
III. Uses and Disclosures of your Protected Health Information
A. Permitted Uses and Disclosures. As a health care provider, Shoshone Medical Center is permitted to use or disclose your protected health information for the following reasons.
· Treatment. We may use and disclose Protected Health Information to provide treatment and other services to you-for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
· Payment. We may use and disclose Protected Health Information to obtain payment for services that we provide to you-for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care.
· Health Care Operations. We may use and disclose Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose Protected Health Information to our quality assurance personnel in order to resolve any complaints you may have and ensure that you have a comfortable visit with us.
B. Use and Disclosure with Your Authorization. We may use or disclose your Protected Health Information for other reasons only when (1) you give us your authorization on our authorization form or (2) there is an exception described in Section IV below. Further, you may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified at the end of this Notice.
IV. Uses and Disclosures Without Your Authorization
A. Use or Disclosure for Treatment, Payment and Health Care Operations without Your Authorization. We may use or disclose your Protected Health Information for purposes of treatment, obtaining payment and our health care operations without your authorization.
B. Use or Disclosure for Directory of Individuals in Shoshone Medical Center. Unless you disagree or object, we may include your name, location in Shoshone Medical Center, general health condition and religious affiliation in a patient directory. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to members of the clergy.
C. Disclosure to Relatives and Close Friends. We may use or disclose Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or the opportunity to agree or object cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that is directly relevant to the person’s involvement with your health care.
D. Fundraising Communications. We may contact you to request a tax-deductible contribution to support important activities of Shoshone Medical Center. In connection with any fundraising, we may disclose to the fundraising staff demographic information about you (e.g., your name, address and phone number) and dates that we provided health care to you. If you do not want to receive any fundraising requests in the future, you may contact our Privacy Office at Shoshone Medical Center.
E. Marketing Communications. We may use or disclose Protected Health Information to identify health-related services and products that may be beneficial to your health and contact you about the services and products. If you do not want to receive these marketing communications in the future, you may contact our Privacy Office at Shoshone Medical Center.
F. Public Health Activities. We may disclose Protected Health Information for the following public health activities and purposes: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
G. Victims of Abuse, Neglect or Domestic Violence. We may disclose Protected Health Information without your authorization if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
H. Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs such as Medicare or Medicaid.
I. Judicial and Administrative Proceedings. We may disclose Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
J. Law Enforcement Officials. We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.
K. Decedents. We may disclose Protected Health Information to a coroner or medical examiner as authorized by law. We may also disclose Protected Health Information to a funeral director.
L. Organ and Tissue Procurement. We may disclose Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
M. Research. We may use or disclose Protected Health Information without your authorization if an Institutional Review Board approves a waiver of authorization for disclosure.
N. Health or Safety. We may use or disclose Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
O. Specialized Government Functions. We may use and disclose Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
P. Workers’ Compensation. We may disclose Protected Health Information as authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs.
V. Your Individual Rights
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to Protected Health Information, you may contact our Privacy Officer at the address or telephone number provided at the end of this Notice. You may also file a written complaint with the Director of the Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, Shoshone Medical Center’s Privacy Officer will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a Request Form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response after reviewing your request.
C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive Protected Health Information by alternative means of communication or at alternative locations.
D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a Record Request Form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we will charge you $10.00 (ten dollars) for the first page and $0.50 (fifty cents) for each page thereafter.
E. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an Amendment Request Form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
F. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you $10.00 (ten dollars) for the first page and $0.50 (fifty cents) for each page thereafter.
G. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around Shoshone Medical Center and on our Internet site at www.shomed.org You also may obtain any new notice by contacting the Privacy Office.
VII. Privacy Office
You may contact our Privacy Officer at:
Shoshone Medical Center
Privacy Office
25 Jacobs Gulch
Kellogg, ID 83837
Telephone Number: (208) 784-7017, extension 491
E-mail: privacy@shomed.org |