Joint Notice of Privacy Practices

DRH Joint Notice of Privacy Practices
DRH Joint Notice of Privacy Practices – Revised 4.11.2003
DRH Joint Notice of Privacy Practices Spanish – Revised 3.27.2003

Effective Date: April 14, 2003
DUNCAN REGIONAL HOSPITAL JOINT 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.

Duncan Regional Hospital (“DRH”), it’s medical staff members, and other health care providers who render care within the hospital constitute an organized health care arrangement. The members of this arrangement will follow this Joint Notice of Privacy Practices when they treat you at the hospital. The members of this arrangement will be permitted to use and disclose your protected health information as indicated in this Notice. However, the members of this arrangement are legally separate, and one member will not have any responsibility for the medical care or professional judgment provided by another, independent member.
If you have any questions about this notice, please contact the Privacy Officer at 580-251-8665.

WHO WILL FOLLOW THIS NOTICE:

This notice describes Duncan Regional Hospital's privacy practices and that of:

All hospital team members.
All members of the organized health care arrangement when they treat you at DRH.
Any health care professional authorized to enter information into your file or record.
Any member of a volunteer group we allow to help you while you are under our care.
All of our Business Associates, including but not limited to our computer software vendors, contracted lab companies and pharmaceutical representatives.

All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share your protected health information with each other for purposes of treatment, payment or health care operations described in this notice.

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION:

We understand that your health information is personal. We are committed to protecting your health information. We create a record of the care and services you receive from DRH. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care.
This notice will tell you about the ways in which we may use and disclose your protected health information for treatment, payment or health care operations and for other purposes permitted by law. It also describes your rights to access and control your protected health information and certain obligations we have regarding the use and disclosure of your protected health information. Protected health information is information about you that identifies you and relates to your past, present or future physical or mental health condition and related health care services.

We are required by law to :

make sure that protected health information that identifies you is kept private;
give you this notice of our legal duties and privacy practices with respect to your protected health information;
follow the terms of the notice that is currently in effect;
accommodate reasonable requests you may have to communicate your health information by alternative means or alternative locations; and
notify you if we are unable to agree to a requested restriction.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION:

The following categories describe different ways that we may use and disclose your protected health information, including sensitive information such as mental health, communicable disease and drug and alcohol abuse information. For each category of uses or disclosures we will explain what we mean. 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. In order to assure compliance with Oklahoma law, we will obtain your general consent to use and disclose your protected health information for purposes of treatment, payment and health care operations. If you do not consent, we cannot provide you treatment except in an emergency or other limited circumstances. Oklahoma law only permits disclosure of communicable disease information (such as HIV, AIDs, Hepatitis, etc.) under the following circumstances: (i) with the patient's written consent; (ii) if release is ordered by a court; (iii) if release is required by the State Department of Health to protect the public; (iv) if release is made to a person exposed to such diseases; (v) if release is required to health professionals, appropriate state agencies or a court to enforce Oklahoma law; (vi) if release is required for statistical purposes without patient identity, or (vii) if release is required to health care providers and related parties for diagnosis and treatment purposes.

For Treatment: We may use your protected health information to provide you with medical treatment or services. For example, we may disclose your health information to doctors, nurses, technicians, medical students, pharmacists, or other personnel who are involved in taking care of you. Different departments of DRH also may share your health information in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose your protected health information to people outside DRH who may be involved in your medical care, such as family members or others we use to provide services that are part of your care.

For Payment: We may use and disclose your protected health information so that the treatment and services you receive may be billed 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 treatment you received so your health plan will pay us or reimburse you. 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. We also may use and disclose your information to obtain payment from third parties that may be responsible for such costs, such as family members. We may use your information to bill you directly for services and items.

For Health Care Operations: We may use and disclose your health information to support our business activities. These uses and disclosures are necessary to run DRH and make sure that all of our patients receive quality care. For example, we may use your health 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 health care providers for review and learning purposes. We may combine the health information we have with health information from other hospitals and physicians 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 health information so others may use it to study health care and health care delivery.

Business Associates: There are some services provided in our organization through contracts with Business Associates. When these services are contracted, we may disclose your protected health information to our Business Associate so that they can perform the job we have asked the them to do. To protect your health information, however, we require the Business Associate to appropriately safeguard your information.

Appointment Reminders: We may use and disclose your protected health information to contact you as a reminder that you have an appointment for treatment or medical care at DRH. We will not leave protected health information on your answering machine or in a message left with the person answering the telephone if you are not at home.

Treatment Alternatives: We may use and disclose protected health 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 your protected health information to tell you about health-related benefits or services offered by us that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may release your protected health information to a friend or family member who is involved in your medical care or to someone who helps pay for your care. In addition, we may disclose your protected health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Directory: Unless you notify us that you object, we may use your name, location in the facility and one-word description of your condition (which may include your death if you die in DRH), and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to the media and other people who ask for you by name. Your religious affiliation may be given to members of the clergy even if they don't ask for you by name.
Fundraising: We may contact you as part of a fundraising effort for DRH. If you do not want to be contacted for fundraising efforts by DRH or a related foundation, you must notify, in writing, the Director of Health Information Management of Duncan Regional Hospital at 1407 Whisenant Drive, PO Box 2000, Duncan, OK, 73534.

SPECIAL SITUATIONS:

Under the following situations, the law may require and or permit DRH to use or disclosure your protected health information without your consent or authorization.
To Avert a Serious Threat to Health or Safety: We may use and disclose protected health 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 or potential organ recipient, we may release your protected health 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 protected health information about you as required by military command authorities. We may also release your protected health information to a foreign military authority, if you are in their service.

Workers' Compensation: We may release protected health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. Release of such information is controlled by state and/ or federal law.

Public Health Risks: We may disclose your protected health information 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 a known or suspected crime;
to report child abuse or neglect;
to report vulnerable adult abuse or neglect;
to report reactions to medications or problems with products;
to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading adisease or condition;
to notify the appropriate government authority if we believe a patient has been the victim of domestic violence.

We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities: We may disclose your protected health 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: If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to a court or administrative order. In some instances we may disclose your protected health information pursuant to a discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release protected health information if asked to do so by a law enforcement official:

in response to a court order and certain subpoenas, warrants, 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 involving DRH ; 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.

Medical Examiners and Funeral Directors: We may release protected health information to a medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release protected health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: We may release protected health 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 protected 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 protected health information about you to the correctional institution or law enforcement official. This release would be necessary

for DRH to provide you with health care;
to protect your health and safety or the health and safety of others; or
for the safety and security of the correctional institution.

Research: Under certain circumstances, we may use and disclose protected health 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 health information, trying to balance the research needs with patients' need for privacy of his or her health information. Before we use or disclose your protected health information for research, the project will have been approved through this research approval process. We may, however, disclose health information about you to members of our workforce preparing to conduct a research project, for example, to help them look for patients with specific medical needs. 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 in our facility.

As Required By Law: We will disclose protected health information about you when required to do so by federal, state or local law.

OTHER USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION:

Other uses and disclosures of protected health 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 protected health 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 protected health 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.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU:

You have the following rights regarding protected health information we maintain about you. All requests and questions regarding these rights must be made in writing and submitted to the Director of Health Information Management of Duncan Regional Hospital at 1407 Whisenant Drive, PO Box 2000, Duncan, OK, 73534.

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care for so long as we maintain that information. This includes medical and billing records. This information does not include psychotherapy notes, records compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative proceeding, or information that is subject to law that prohibits access to such information.

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. By statute in Oklahoma, we may charge you $0.25 per page for copies, plus our postage costs. If your record contains any item that requires a photographic process to copy, such as an x-ray or photograph, we may charge you up to $5.00 per image.

Right to Amend: If you feel that health 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 DRH.

You must provide a reason that supports your amendment 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 health information kept by DRH;
is not part of the information which you would be permitted to inspect and copy; or
in our judgment is accurate and complete as it appears or as it was at the time it was originally captured and recorded.

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we have made of your health information outside the scope of treatment, payment and health care operations, and which were not released pursuant to an authorization or released as a part of our directory information.

Your request must state a time period, which may not be longer than six years and may not include dates before Apri114, 2003. The first list you request within each 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 costs are incurred.

Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. However, we must receive your restrictions in writing before we have made such disclosures. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care. For example, you can request that we not disclose certain medical information to your health insurance company for payment purposes.

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.

If you request restrictions, 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.

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, at home, by mail, or by phone. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request.

Right to a Copy of This Notice: You have the right to a copy of this notice. You may ask us to give you a copy of this notice at any time. You may also obtain a copy of this notice at our website, www.duncanregional.com.

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 protected health 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 our facility as well as on our website. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you present for treatment or health care services, you will have the opportunity to receive a copy of the current notice in effect.

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with Duncan Regional Hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with DRH, contact the Privacy Officer of Duncan Regional Hospital at 1407 Whisenant Drive, PO Box 2000, Duncan, OK, 73534. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

DUNCAN REGIONAL HOSPITAL Privacy Policy and Procedures

Subject: Joint Notice of Privacy Practices Policy
Effective Date: April 14, 2003
Approved: Pat Andersen (Signed Original in Health Information Management)
Revised: April 11, 2003 Reviewed: November 2008

PURPOSE

To establish the requirements for notifying a patient of the use and disclosure of his/her protected health information by DRH, it’s medical staff members, and other health care providers who render care within the hospital.

POLICY

A "Joint Notice of Privacy Practices" will be used by DRH to give patients a clear written explanation of how DRH will use, keep, and disclose the patient's PHI. It also contains information on the patient’s rights regarding his or her PHI. The notice will be provided to every patient, posted in clear and prominent locations and will also be available on the DRH web site at www.duncanregional.com.

PROCEDURE

The "Joint Notice of Privacy Practices" will be posted in prominent areas of DRH as well as on the DRH web site. It will be made available to each individual patient when presenting for services. In addition, the notice shall be given to any person who requests it, regardless if he or she is a current patient.
The patient will be asked to sign a "General Consent" after receiving the “Joint Notice of Privacy Practices” to acknowledge that he or she received and understands the "notice and to consent to the use of PHI for treatment, payment and health care operations.
The signed “General Consent” form will become a part of the patient's medical record and must be maintained for a minimum of six (6) years from the date of its creation. If a patient refuses to sign the consent form, such refusal shall be documented by the staff on the form.
If the “Joint Notice of Privacy Practices” is revised in a manner that materially changes the use, disclosure or the patient's rights, a copy of the revised notice must be made available upon request, and a good faith effort must be made to obtain the patient's acknowledgement of his or her receipt of the revised notice.
The following provisions will be addressed in the "Joint Notice of Privacy Practices":
- Effective date of the notice
- Who the patient may contact with questions about the notice
- Who will follow the notice
- DRH's pledge regarding the patient's PHI How DRH may use and disclose a patient's PHI
- Special Situations: This section will list special situations that may arise in which a patient's PHI may be used or disclosed. Each category will provide a brief explanation and example of how PHI may be used or disclosed.
- A patient's rights regarding his or her PHI that is maintained by the DRH
- Changes to the notice
- Complaints
- Other uses of PHI