DAVIESS COMMUNITY HOSPITAL
JOINT NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE: 04/14/03
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 the Privacy Officer or designee.
1314 East Walnut , Washington IN 47501
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We are required by law to maintain the privacy of your medical information and to provide you with notice of our legal duties and privacy practices regarding medical information. We are required to abide by the terms of the notice currently in effect. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT 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 give you some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.
We may use your medical information to provide you with treatment
We may disclose your medical information to doctors, nurses, technicians , medical students, or other personnel who are involved in taking care of 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. Different departments may share medical information about you in order to coordinate the different things you need. We also may disclose medical information about you to providers outside Daviess Community Hospital who may be involved in your medical care after you leave. In addition, we may disclose your medical information to other health care providers who need it to provide treatment to you.
We may use and disclose your medical information to bill and collect payment for treatment and services provided to you.
FOR EXAMPLE: We may give your health information to your insurance company about treatment you received so they will pay us or reimburse you. We may also tell your insurance about treatment you are going to receive to obtain prior approval or find out whether they will pay for the treatment. We may also disclose your medical information to other providers or health plans for their payment activities as they relate to your treatment.
FOR HEALTH CARE OPERATIONS.
We may use and disclose medical information about you for our business operations. These uses and disclosures are necessary to run Daviess Community Hospital and make sure that all of our patients receive quality care.
We may also disclose your medical information to another health care provider or payor for certain health care operation activities of that entity, if that entity also has a relationship to you.
FOR EXAMPLE: We may use medical information to review our treatment and services and to evaluate our
We may combine medical information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective.
We may disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes.
We may combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer.
We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
We may disclose your medical information to our accreditation organizations while they review our operations for accreditation purposes.
APPOINTMENT REMINDERS. We may use and disclose your medical information to remind you of appointments, annual exams, or prescription refills.
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. For example, this may include specific brand name or over the counter pharmaceuticals.
HEALTH-RELATED BENEFITS AND SERVICES. We may use and disclose medical information to tell you about health-related benefits or services which may be of interest to you. For example, this may include new tests or procedures that we offer.
THIRD PARTIES. We may disclose your medical information to certain third parties with who we contract to perform services on our behalf. If we disclose your information to these entities, we will have an agreement with them to safeguard your information.
INCIDENTAL USES AND DISCLOSURES. We may occasionally inadvertently use or disclose your medical information when such use or disclosure is incident to another use or disclosure that is permitted or required by law.
FOR EXAMPLE: While we have safeguards in place to protect against others overhearing our conversations that take place between doctors, nurses or other DCH personnel, there may be times that such conversations are in fact overheard. Please be assured, however, that we have appropriate safeguards in place to avoid such situations, and others, as much as possible.
DISCLOSURES TO YOU. Upon a request by you, we may use or disclose you medical information in accordance with your request.
LIMITED DATA SETS. We may use or disclose certain parts of your medical information, called a “limited data set,” for purposes of research, public health reasons or for our health care operations. We would disclose a limited data set only to third parties who have provided us with satisfactory assurances that they will use or disclose your medical information only for limited purposes.
DISCLOSURE TO THE SECRETARY OF HEALTH AND HUMAN SERVICES. We might be required by law to disclose your medical information to the Secretary of the Department of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether we are complying with privacy laws.
DE-IDENTIFIED INFORMATION. We may use your medical information, or disclose it to a third party whom we have hired, to create information that does not identify you in any way. Once we have de-identified your information, it can be used or disclosed in any way according to law.
DISCLOSURES BY MEMBERS OF OUR WORKFORCE. Members of our workforce, including employees, volunteers, trainees or independent contractors, may disclose your medical information to a health oversight agency, public health authority, health care accreditation organization or attorney hired by the workforce member, to report the workforce members belief that we have engaged in unlawful conduct or that our care or services could endanger a patient, workers or the public. In addition, if a workforce member is a crime victim, the member may disclose your medical information to a law enforcement office.
FUNDRAISING ACTIVITIES. We may use medical information to contact you in an effort to raise money. We may disclose medical information to a foundation related to Daviess Community Hospital so that the foundation may contact you in raising money. We only release contact information, such as your name, address and phone number and the dates you received treatment or services. If you do not want to be contacted for fundraising efforts, you must notify the Manager of Marketing Department or designee in writing at DCH.
HOSPITAL DIRECTORY. We may include certain limited information about you in the hospital directory while you are a patient. 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. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. You will have an opportunity to agree or object to your information being included in the directory at the time of admission.
INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE.
We may release medical information about you to a friend, family member, or other person identified by you who is involved in your medical care. We may also tell your family or friends your condition and that you are in the hospital. Additionally, we may give information to someone who is involved with or helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in disaster relief effort so that your family can be notified about your condition, status and location. If you do not want this information shared, please let an employee in the Admitting office know.
RESEARCH. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example:
We may release information about you to researchers preparing to conduct a research project so long as the medical information does not leave the hospital. Oftentimes, researchers need to know how many patients have a specific health problem in order to prepare a research project.
We may also use and disclose medical information about you for research purposes if
In other studies, if a doctor caring for you believes you may be interested in, or benefit from, a research study, your doctor and the committee will approve someone to contact you to see if you are interested in the study. At that time, you would be contacted with more information and you would have the right to authorize continued contact or refuse further contact.
the research has been subjected to a careful review process conducted by a specially selected and trained committee and received this committee’s approval. This process evaluates a proposed research project and its use of medical information, and balances the potential benefit of the research against individual patients’ need for privacy of their medical information. This type of 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.
Lastly, if certain criteria are met, we may disclose your medical information to researchers after your death when it is necessary for research purposes.
REQUIRED BY LAW. We will disclose your medical information when required to do so by federal, state, or local law.
DISCLOSURES OF MEDICAL INFORMATION OF MINORS. Under Indiana law, we cannot disclose the medical information of minors to non-custodial parents if a court order or decree is in place that prohibits the non-custodial parent from receiving such information. However, we must have documentation of the court order prior to denying the non-custodial parent such access.
DISCLOSURES OF RECORDS CONTAINING DRUG OR ALCOHOL ABUSE INFORMATION. Because of federal law , we will not release your medical information if it contains information about drug or alcohol abuse without your written permission except in very limited situations.
DISCLOSURES OF MENTAL HEALTH RECORDS. If your records contain information regarding your mental health, we are restricted in the ways that we can use and disclose them. We can disclose such records without written permission only in the following situations:
If the disclosure is made to you (unless it is determined by a physician that the release would be detrimental to your health);
Disclosures to our employees in certain circumstances;
For payment purposes;
For data collection, research, and monitoring managed care providers if the disclosure is made to the
division of mental health;
For law enforcement purposes or to avert a serious threat to the health and safety of you or others;
To a coroner or medical examiner;
To satisfy reporting requirements;
To another provider in an emergency;
For legitimate business purposes;
Under a court order;
To the Secret Service if necessary to protect a person under Secret Service protection; and
To the Statewide waiver ombudsman.
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 or to law enforcement authorities in particular circumstances.
ORGAN AND TISSUE DONATION. We may release medical information to organizations that handle organ procurement 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.
WORKERS’ COMPENSATION. We may release medical information about you as authorized by and to the extent necessary to comply with workers’ compensation laws or laws relating to 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 or adult abuse or neglect;
To report reactions to medications 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 the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
To notify your employer if we treat you and such notification is required 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 health care system, government programs, and compliance with civil rights laws.
LAWSUITS AND DISPUTES. We may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell you about the request, in which you were given an opportunity to object to the request, or to obtain an order protecting the information requested.
LAW ENFORCEMENT. We may release medical information if asked to do so by a law enforcement official, if such disclosure is:
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.
Except for the first two (2) disclosures, the information disclosed will be limited to your contact information or physical characteristics.
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 treated by 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.
SUSPECTED ABUSE OR NEGLECT. If we believe that a person is a victim of child or adult abuse or neglect, we are required by law to report certain information to public authorities.
COMMUNICATIONS REGARDING OUR SERVICES OR PRODUCTS. We may use and disclose your medical information to make a communication to you to describe a health-related product or service of Daviess Community Hospital. In addition, we may use or disclose your medical information to tell you about products or services related to your treatment, case management or care coordination, or alternative treatments, therapies, providers or settings of care for you. We may occasionally tell you about another company’s products or services, but will use or disclose your medical information for such communications only if they occur in person with you. We may also use and disclose your medical information to give you a promotional gift from us that is a minimal value.
INMATES. An inmate of a correctional institution or an individual under the custody of a law enforcement official does not have rights listed in this Notice of Privacy Practices. We may release medical information about you to the correctional institutional or law enforcement official. Except for disclosures to another provider for your treatment, the information disclosed will be limited to your contact information or physical characteristics.
YOUR RIGHTS REGARDING MEDICAL INFORMATION 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 Manager, Health Information Department or designee at DCH. 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 health care 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.
·RIGHT TO AMEND If you believe that medical information we have about you is not accurate or incomplete, you have the right to request an amendment.
To request an amendment, your request must be made in writing and submitted to the Manager, Health Information Department or designee at DCH. In addition, you must provide a reason that supports your request. This process does not include changes to PHI (protected health information) in demographic information (address, phone #, name change, etc).
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 respond to 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 certain disclosures that we have made of your medical information.
To request this list or accounting of disclosures, you must submit your request in writing to the Manager, Health Information Department or designee at DCH. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists during such twelve (12) month period, 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.
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 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 the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information to a particular family member about a surgery you had.
We are not required to to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Health Information Department. 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, disclosures 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 contact you only at work or by mail.
To request confidential communications, you must make your request in writing to the Privacy Officer or designee, Daviess Community Hospital, 1314 E. Walnut, Washington, IN 47501-0760. 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 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 website,
To obtain a paper copy of this notice, contact the person
in Admitting /Registration at DCH
CHANGES TO 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 create or receive in the future. We will post a copy of the current notice in all Daviess Community Hospital facilities. The notice will contain the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services we will make a copy of the current notice in effect available to you upon request.
COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with Daviess Community Hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, to obtain further information regarding filing of complaints or to obtain other information provided in the Notice, contact the Manager, Risk Management Department at DCH. 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.
WHO THIS NOTICE APPLIES TO. This notice describes DCH’s practices and those of:
Any health care professional authorized to enter information into or consult your medical record’;
All departments and units of DCH;
Any member of a volunteer group we allow to help you;
All employees, staff and other hospital personnel, and any residents or student trainees that we allow to
train at the hospital;
DCH’s medical staff and its member; attending physicians; radiologist; pathologists; anesthesiologist; surgeons; internal medicine physicians; emergency department physicians; and any other physician or health care provider who provides treatment to you while you are at or in the hospital, and staff members of such physicians who work at the hospital. All of these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or operations purposes described in this notice.