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Bothwell Regional Health Center Notice of Privacy Practices



Effective Date: April 16, 2002                              Revision Date: 03-29-10, 08-22-13

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.

This notice serves as a joint notice for Bothwell Regional Health Center affiliated hospitals and providers (collectively referred to herein as “we” or “our”). Because we are affiliated healthcare providers as defined by the Health Insurance Portability and Accountability Act of 1996, we have elected to prepare a joint notice concerning our privacy practices. We will follow the terms of this notice and may share health information with each other for purposes of treatment, payment and health care operations as described in this Notice.

OUR DUTIES REGARDING YOUR HEALTH INFORMATION

We respect the confidentiality of your health information and recognize that information about your health is personal. We are committed to protecting your health information and to informing you of your rights regarding such information. We are by law to protect the privacy of your protected health information and to provide you with notice of these legal duties. This notice explains how, when and why we typically use and disclose health information and your privacy rights regarding your health information. In our notice we refer to our uses and disclosures of health information as our “Privacy Practices.” Protected health information generally includes information that we create or receive that identifies you and your past, present or future health status or care or the provision of or payment for that health care. We are obligated to abide by these Privacy Practices as of the effective date listed above.

We may, however, change our privacy practices in the future and specifically reserve our right to change the terms of this notice and our privacy practices. We will communicate any change in our Notice of Privacy Practices as described at the end of this notice. Any changes that we make in our privacy practices will affect any protected health information that we maintain.

Generally, our Privacy Practices strive: Ÿ
  • To make sure that health information that identifies you is kept private;
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  • To give you this Notice of our Privacy Practices and legal duties with respect to protected health information;
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  • To follow the terms of the Notice that is currently in effect, and;
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  • To make a good faith effort to obtain from you a written acknowledgement that you have received or been given an opportunity to receive this notice.
BOTHWELL REGIONAL HEALTH CENTER PROVIDERS INCLUDED IN THIS NOTICE

Our notice serves as a joint notice for all Bothwell Regional Health Center affiliated entities, sites and locations, each of which will follow the terms of this notice. Specifically, our notice describes our privacy practices and that of: Ÿ
  • Any Bothwell Regional Health Center affiliated hospital and the healthcare professionals authorized to enter information into your hospital chart; Ÿ
  • All our departments and units, including Bothwell Regional Health Center clinics, Bothwell Medical Equipment, diagnostic centers, rehabilitations offices and pharmacy;
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  • All physicians employed by us and their practice sites;
  • All hospital-based physicians such as anesthesiologists, pathologists and radiologists.
  • Any member of a volunteer group we allow to help you while you are in one of our hospitals or while receiving care from us; and
  • All employees, staff and other healthcare personnel, including those employees or personnel of any other Bothwell Regional Health Center entity not mentioned above.
Our notice does not address the privacy practices that your personal doctor (if not employed by us) may use in his or her private office and will not affect the medical decisions he or she makes in your care and treatment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We use and disclose your protected health information in a variety of circumstances and for different reasons. Many of these uses and disclosure require your prior authorization. There are situations, however, in which we may use and disclose your health information without your authorization. Many of these uses and disclosures will occur with your treatment, for payment of your health services or for our healthcare operations.

There are additional situations, however, where the law permits or requires us to use and disclose your health information without your authorization. Examples of these situations will also be described in this section of the notice.

Specifically, we may use and disclose your protected health information as follows:

For Treatment, Payment and Health Care Operations
1. For Your Treatment. We may use and/or disclose your protected health information to physicians, nurses, dietitians, technicians, residents, medical or other health professional students, physical therapists or other personnel who are involved in your care and who will provide you with medical treatment or services. For example, if you have had surgery or just had a baby, we may contact a home health care agency to arrange for home services or to check on your recovery after you are discharged from the hospital.
2. For Payment of Health Services that You Receive. We may use and/or disclose your protected health information to bill and receive payment for the health services you receive from us. For example, we may provide your health information to our billing or claims department to prepare a bill or statement to send to your insurance company, including Medicare or Medicaid, or another group or individual responsible for payment of your health services. Bothwell Regional Health Center will restrict the disclosure of protected health information for payment of healthcare operations to a health plan when a patient pays for the service or items in question out of pocket. Bothwell Regional Health Center will not release genetic information (i.e., genetic tests, individual/family health history, etc.) for disclosure to health plans for use in underwriting purposes.
3. For Our Health Care Operations. We perform many activities to help assess and improve the health or other services that we provide. Such activities include participating in medical or nursing training programs or education, performing quality reviews, conducting patient opinion surveys, developing clinical guidelines and protocols, engaging in case management and care coordination, business management, insurance or legal compliance reviews, participating in accreditation surveys such as the Joint Commission for the Accreditation of Healthcare Organizations. These activities are referred to as “healthcare operations.” We may use and/or disclose health information for purposes of any of these healthcare operations. Additionally, we may disclose health information to auditors, accountants, attorneys, government regulators, or other consultants to assess and/or ensure our compliance with laws or to represent us before regulatory or other governing authorities or judicial bodies.
4. For Another Provider’s Treatment, Payment or Healthcare Operations. The law permits us to disclose your protected health information to another healthcare provider involved with your treatment to enable that provider to treat you and get paid for those services as well as for that provider’s healthcare operations involving quality reviews, assessments or compliance audits.
5. Special Circumstances When We May Disclose Your Health Information Related to Treatment, Payment or Healthcare Operations. After removing direct identifying information (such as your name, address and social security number) from the health information, we may use your health information for research, public health activities or other healthcare operations (such as business planning). While only limited identifying information will be used, we will also obtain certain assurances from the recipient of such health information that they will safeguard the information and only use and disclose the information for limited purposes. Additionally, we may disclose health information to outside organizations or providers for them to provide services to you on our behalf. We will also seek written assurances from these providers to safeguard the health information that they receive.
6. Most uses and disclosure of psychotherapy notes will require authorization.

For Permitted or Required by Law Activities

There are circumstances where we may use and/or disclose your health information without first obtaining your written authorization for purposes other than for treatment, payment or healthcare operations. Except for specific situations where the law requires us to use and disclose information (such as reports of birth to the health department or reports of abuse or neglect to social services), we have listed all these permitted uses and disclosure in this section.
1. For Public Health Activities. We may use or disclose health information to a public health authority that is authorized by law to collect or receive information in order to report communicable diseases and child abuse, or to the FDA to report medical device or product related events. In certain limited situations, we may also disclose information to notify a person exposed to a communicable disease.
2. For Health Oversight Activities. We may disclose health information to a health oversight agency that includes an agency of the federal or state government that is authorized by law to monitor the healthcare system.
3. For Law Enforcement Activities. We may disclose limited information in response to a law enforcement official’s request for information to identify or locate a victim, a suspect, a fugitive, a material witness or a missing person, including individuals who have died, or for reporting a crime that has occurred on our premises or that may have caused a need for emergency services.
4. For Judicial and Administrative Proceedings.
We may disclose health information in response to a subpoena, order of a court or administrative tribunal.
5. To Coroners, Medical Examiners and Funeral Directors.
We may disclose identifying information related to an individual’s death to coroners, medical examiner, funeral directors or next of kin.
6. For Purposes of Organ Donation.
We may disclose health information to an organ procurement organization or other facility that participates in the procurement, banking or transplantation of organs or tissues.
7. For Purpose of Research.
We can conduct and participate in medical, social, psychological and other types of research. Most research projects are subject to a special approval process to evaluate the proposed research project and its use of health information before we use or disclose health information. In certain circumstances, however, we may disclose health information to people preparing to conduct a research project to help them determine whether a research project can be carried out or will be useful, so long as the health information they review does not leave our premises. Additionally, because we are committed to advancing science and medicine and as a part of your treatment, our clinicians may offer you information about clinical research trials. Todetermine whether you are a candidate for certain clinical trials, our clinicians and research personnel may occasionally review your medical records and compare your information to the clinical trial requirements.
8. To Avoid Harm to a Person or for Public Safety.
We may use and disclose health information if we believe that the disclosure is necessary to prevent or lessen a serious threat or harm to the public or the health or safety of another person.
9. For Specialized Government Functions.
We may use and disclose health information of certain military individual, for specific government security needs, or as needed by correctional institutions.
10. For Workers’ Compensation Purposes.
We may disclose your health information to comply with the workers’ compensation laws or other similar programs.
11. For Appointment Reminders and to Inform You of Health Related Products or Services. We may use or disclose your health information in order for us to contact you for appointments or other scheduled services, or to provide you with information about treatment alternatives or other health-related products and service.

When your preferences will guide our use or disclosure


While the law permits certain uses and disclosures without your authorization, the law also provides you with an opportunity to inform us of your preference, in certain limited situations, concerning the use or disclosure or your health information. For these limited uses and disclosures, we may simply ask and you may simply tell us your preference concerning the use or disclosure of your health information. These limited situations include the following:
1. Facility directory information on the individuals who are receiving health services from us. A facility directory may include your name, your location in the facility, your general condition and your religious affiliation, if provided by you. Unless you tell us that you do not want to be included in the facility directory, you will be included, and directory information may be disclosed to members of the clergy or to people who ask for you by name.
2. The information, if any, given to your family or friends. Unless you tell us otherwise prior to a discussion, we may disclose to a family member or a close personal friend health information concerning your care, including information concerning the payment for your care.

All Other Uses and Disclosures Require Your Prior Written Authorization

For situations not generally described in our notice, we will ask for your written authorization before we use or disclose your health information. You may revoke that authorization, in writing, at any time to stop future disclosures of your information. Information previously disclosed, however, will not be requested to be returned, nor will your revocation affect any action that we have already taken. In addition, if we collected the information in connection with a research study, we are permitted to use and disclose that information to the extent it is necessary to protect the integrity of the research study.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

This portion of our notice describes your individual privacy rights regarding your health information and how you may exercise those rights.

Regarding Restrictions of Certain Uses and Disclosures of Health Information

You may request, in writing, a restriction on how we use or disclose your protected health information for your treatment, for payment of your healthcare services or for activities related to our healthcare operations. You may also request a restriction on what health information we may disclose to someone who is involved in your care, such as a family member or friend. You must make a request to Health Information Management or other designated department. We are not required to agree to your request. Additionally, any restriction that we may approve will not affect any us or disclosure that we are legally required or permitted to make under the law, including our facility directory.

Fundraising/Marketing/Sales

Fundraising.
Bothwell Regional Health Center and its affiliates, such as the Bothwell Regional Health Center Foundation, may occasionally use patient data as allowed by the provisions of the Health Insurance Portability and Accountability Act to raise funds to benefit the organization and its programs. Patients receiving these communications may at any time opt out of receiving any future fund-raising communications. Patients who do not wish to receive these communications may contact the Bothwell Foundation at foundation@brhc.org or by calling 660-826-6263 to communicate that they do not wish to receive this information.

Marketing. Bothwell Regional Health Center and its affiliates may use patient data to communicate about new health services, alternative treatments, care coordination and other relevant developments as allowed by the provisions of the Health Insurance Portability and Accountability Act. Any other related use of patient data requires the express written authorization of the patient or legal representative. Bothwell Regional Health Center and its affiliates do not share or sell patient data to third-party marketers.

Sale of Protected Health Information. Bothwell Regional Health Center will not sell protected health information to third parties without written authorization from a patient or legal representative.

Requesting Confidential Communication

You may request and receive reasonable changes in the manner or the location where we may contact you for appointment reminders, lab results or other related information. You must make your request in writing to Health Information Management or designated department that maintains your health information and you must specify the alternate method or location where you wish to be contacted and how you will handle payment for your health services. We will accommodate your reasonable request but in determining whether your request is reasonable, we may consider the administrative difficulty it may impose on us.

Inspecting and Obtaining Copies of Your Health Information

You may ask to look at or obtain a copy of your health information. You must make your request in writing to Health Information Management. We may charge a fee for copying or preparing a summary of requested health information. We will generally respond to your request for health information within 30 days of receiving your request, unless your health information is not readily accessible, or the information is maintained in an off-site storage location.

Requesting a Change in Your Health Information

You may request, in writing, a change or addition to your health information. You must make your request in writing to Health Information Management. The law limits your ability to change or add to your health information. These limitations include whether we created or included the health information. These limitations include whether we created or included the health information within our medical records or if we believe that the health information is accurate and complete without any changes. Under no circumstances, will we erase or otherwise delete original documentation in your health information.

Requesting an Accounting of Disclosures of Your Health Information

You may ask in writing for an accounting of certain types of disclosures made of your health information. The law excludes from an accounting many of the typical disclosures, such as those made to care for you, to pay for your health services or where you had provided your written authorization to the disclosure. You must make your request to Health Information Management. Generally, we will respond to your request within 60 days of receiving your request unless we need additional time.

Breach Notification

An individual has the right to be notified when a breach of his or her unsecured protected health information has occurred.

Obtaining a Notice of Our Privacy Practices

We will provide you with our notice to explain and inform you of our privacy practices. You may also take a copy of this notice with you. Even if you have requested this notice electronically, you may still request a paper copy at any time. You may also view or obtain a copy of our notice at the Bothwell Regional Health Center website www.brhc.org.

CHANGES TO THIS NOTICE

We reserve the right to change this notice concerning our privacy practices affecting all the health information that we now maintain as well as information that we may receive in the future. We will provide you with the revised notice by making it available to you upon request during treatment or admission, by posting it at our service sites as well as posting het revised Notice on our website.

COMPLAINTS

We welcome an opportunity to address any concerns that you may have regarding the privacy of your health information. If you believe that the privacy of your health information has been violated, you may file a complaint with our Patient Advocate, Privacy Officer, Health Information Management director, or Corporate Compliance Officer.

You may contact the Patient Advocate, Privacy Officer, Health Information Management director or Corporate Compliance Officer, who will assist you, or contact the Operator at any of our facilities or offices and request the Patient Advocate, Privacy Officer or Health Information Management director. A dedicated phone number of 800-887-8833 or 660-829-7715 is available or, if you wish, you may email your concerns to privacy@brhc.org.

It is important to note that requests or complaints must be made to the hospital or office where your privacy concern arose. Any requests or complaints made will not be deemed to be filed with any of the other hospitals or providers covered by or addressed in this joint notice.

In addition, you may also file a written complaint with the Secretary of the US Department of Health & Human Services at: US Department of Health & Human Services, 200 Independence Avenue, SW, Washington, DC 20201, 202-619-0257; Toll free 877-696-6775.

YOU WILL NOT BE PENALIZED OR RETALIATED AGAINST FOR FILING A COMPLAINT.