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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 takes
effect on SEPTEMBER
1ST 2004
and remains in effect until we replace it.
1. OUR PLEDGE REGARDING MEDICAL
INFORMATION
The privacy of your
medical information is important to us. We understand that your
medical information is personal and we are committed to protecting
it. We create a record of the care and services you receive at our
organization. We need this record to provide you with quality care
and to comply with certain legal requirements. This notice will tell
you about the ways we may use and share medical information about
you. We also describe your rights and certain duties we have
regarding the use and disclosure of medical information.
2. OUR LEGAL
DUTY
Law Requires Us
to:
1. Keep your medical
information private.
2. Give you this
notice describing our legal duties, privacy practices, and your
rights regarding your medical information.
3. Follow the terms
of the notice that is now in effect.
WE HAVE THE RIGHT
TO:
1. Change our privacy
practices and the terms of this notice at any time, provided that
the changes are permitted by law.
2. Make the changes
in our privacy practices and the new terms of our notice effective
for all medical information that we keep, including information
previously created or received before the changes.
Notice of Change to Privacy
Practices:
1. Before we make an
important change in our privacy practices, we will change this
notice and make the new notice available upon request.
3. USE AND DISCLOSURE OF YOUR
MEDICAL INFORMATION
The following section
describes different ways that we use and disclose medical
information. Not every use or disclosure will be listed. However, we
have listed all of the different ways we are permitted to use and
disclose medical information. We will not use or disclose your
medical information for any purpose not listed below, without your
specific written authorization. Any specific written authorization
you provide may be revoked at any time by writing to us
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 people who
are taking care of you. We may also share medical information about
you to your other health care providers to assist them in treating
you.
FOR PAYMENT: We may use and
disclose your medical information for payment purposes.
FOR HEALTH CARE OPERATIONS:
We may use and disclose your medical information for our health care
operations. This might include measuring and improving quality,
evaluating the performance of employees, conducting training
programs, and getting the accreditation, certificates, licenses and
credentials we need to serve you.
ADDITIONAL USES AND
DISCLOSURES: In addition to using and disclosing your medical
information for treatment, payment, and health care operations, we
may use and disclose medical information for the following
purposes.
Facility Directory:
Unless you notify us that you object, the following medical
information about you will be placed in our facilities’ directories:
your name; your location in our facility; your condition described
in general terms; your religious affiliation, if any. We may
disclose this information to members of the clergy or, except for
your religious affiliation, to others who contact us and ask for
information about you by name.
Notification: Medical
information to notify or help notify: a family member, your personal
representative or another person responsible for your care. We will
share information about your location, general condition, or death.
If you are present, we will get your permission if possible before
we share, or give you the opportunity to refuse permission. In case
of emergency, and if you are not able to give or refuse permission,
we will share only the health information that is directly necessary
for your health care, according to our professional judgment. We
will also use our professional judgment to make decisions in your
best interest about allowing someone to pick up medicine, medical
supplies, x-ray or medical information for you.
Disaster Relief: Medical
information with a public or private organization or person who can
legally assist in disaster relief efforts.
Fundraising: We may
provide medical information to one of our affiliated fundraising
foundations to contact you for fundraising purposes. We will limit
our use and sharing to information that describes you in general,
not personal, terms and the dates of your health care. In any
fundraising materials, we will provide you a description of how you
may choose not to receive future fund raising communications.
Research in Limited
Circumstances: Medical information for research purposes in
limited circumstances where the research has been approved by a
review board that has reviewed the research proposal and established
protocols to ensure the privacy of medical information.
Funeral Director, Coroner,
Medical Examiner: To help them carry out their duties, we may
share the medical information of a person who has died with a
coroner, medical examiner, funeral director, or an organ procurement
organization.
Specialized Government
Functions: Subject to certain requirements, we may disclose or
use health information for military personnel and veterans, for
national security and intelligence activities, for protective
services for the President and others, for medical suitability
determinations for the Department of State, for correctional
institutions and other law enforcement custodial situations, and for
government programs providing public benefits.
Court Orders and Judicial and
Administrative Proceedings: We may disclose medical information
in response to a court or administrative order, subpoena, discovery
request, or other lawful process, under certain circumstances. Under
limited circumstances, such as a court order, warrant, or grand jury
subpoena, we may share your medical information with law enforcement
officials. We may share limited information with a law enforcement
official concerning the medical information of a suspect, fugitive,
material witness, crime victim or missing person. We may share the
medical information of an inmate or other person in lawful custody
with a law enforcement official or correctional institution under
certain circumstances.
Public Health Activities:
As required by law, we may disclose your medical information to
public health or legal authorities charged with preventing or
controlling disease, injury or disability, including child abuse or
neglect. We may also disclose your medical information to persons
subject to jurisdiction of the Food and Drug Administration for
purposes of reporting adverse events associated with product defects
or problems, to enable product recalls, repairs or replacements, to
track products, or to conduct activities required by the Food and
Drug Administration. We may also, when we are authorized by law to
do so, notify a person who may have been exposed to a communicable
disease or otherwise be at risk of contracting or spreading a
disease or condition.
Victims of Abuse, Neglect, or
Domestic Violence: We may disclose medical information to
appropriate authorities if we reasonably believe that you are a
possible danger to health or safety of others. We may share
medical information when necessary to help law enforcement officials
capture a person who has admitted to being part of a crime or has
escaped from legal custody.
Workers Compensation: We
may disclose health information when authorized and necessary to
comply with laws relating to workers compensation or other similar
programs.
Health Oversight
Activities: We may disclose medical information to an agency
providing health oversight for oversight activities authorized by
law, including audits, civil, administrative, or criminal
investigations or proceedings, inspections, licensure or
disciplinary actions, or other authorized activities.
Law Enforcement:
Under certain circumstances, we may disclose health information to
law enforcement officials. These circumstances include reporting
required by certain laws (such as the reporting of certain types of
wounds), pursuant to certain subpoenas or court orders, reporting
limited information concerning identification and location at the
request of a law enforcement official, reports regarding suspected
victims of crimes at the request of a law enforcement official,
reporting death, crimes on our premises, and crimes in
emergencies.
4. YOUR INDIVIDUAL
RIGHTS
You Have a Right
to:
1. Look at or get copies of
your medical information. You may request that we provide copies
in a format other than photocopies. We will use the format you
request unless it is not practical for us to do so. You must make
your request in writing.
2. Receive a list of all the
times we or our business associates shared your medical
information for purposes other than treatment, payment, and health
care operations and other specified exceptions.
3. Request that we place
additional restrictions on our use or disclosure of your medical
information. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except
in the case of an emergency).
4. Request that we
communicate with you about your medical information by different
means or to different locations. Your request that we communicate
your medical information to you by different means or at different
locations must be made in writing to the contact person listed at
the end of this notice
5. Request that we change
your medical information. We may deny your request if we did not
create the information you want changed or for certain other
reasons. If we deny
your request, we will
provide you a written explanation. You may respond with a statement
of disagreement that will be added to the information you wanted
changed. If we accept your request to change the information, we
will make reasonable efforts to tell others, including people you
name, of the change and to include the changes in any future sharing
of that information.
6. If you have received
this notice electronically, and wish to receive a paper copy, you
have the right to obtain a paper copy by making a request in writing
to the Privacy Officer at your office.
QUESTIONS AND
COMPLAINTS
If you have any
questions about this notice or if you think that we may have
violated your privacy rights, please contact us. You may also submit
a written complaint to the U.S. Department of Health and Human
Services. We will provide you with the address to file your
complaint with the U.S. Department of Health and Human Services. We
will not retaliate in any way if you choose to file a
complaint. | 
