|
PRIVACY
POLICY
|
|
 Download
Printable PDF Version -
 |
Click here to download Acrobat Reader if you are unable
to view the documents in PDF format. |
|
|
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.
WHO WILL FOLLOW THIS NOTICE
This notice describes our hospital’s practices and that
of:
Ø
Any health care professional authorized to enter information into
your hospital chart.
Ø
All departments and units of the hospital.
Ø
Any member of a volunteer group we allow to help you while you are
in the hospital.
Ø
All employees, staff and other hospital personnel.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We are required by law to:
·
make sure that medical information that identifies you is kept
private;
·
give you this notice of our legal duties and privacy practices
with respect to medical information about you; and
·
follow the terms of the notice that is currently in effect.
Ø
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 hospital personnel who are
involved in taking care of you at the hospital.
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.
In addition, the doctor may need to tell the dietitian if you have
diabetes so that we can arrange for appropriate meals. Different departments of
the hospital also may share medical information about you in order to coordinate
the different things you need, such as prescriptions, lab work and x-rays.
We also may disclose medical information about you to people outside the
hospital who may be involved in your medical care after you leave the hospital,
such as family members, clergy or others we use to provide services that are
part of your care.
Ø
For Payment.
We may use and disclose medical information about you so that the
treatment and services you receive at the hospital may be billed to 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
surgery you received at the hospital so your health plan will pay us or
reimburse you for the surgery. 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.
Ø
For Health Care
Operations. We may use and
disclose medical information about you for hospital operations.
These uses and disclosures are necessary to run the hospital and make
sure that all of our patients receive quality care.
For example, we may use medical information to review our treatment and
services and to evaluate the performance of our staff in caring for you.
We may also combine medical information about many hospital patients to
decide what additional services the hospital should offer, what services are not
needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses,
technicians, medical students, and other hospital personnel for review and
learning purposes. We may also
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.
Ø
Appointment Reminders.
We may use and disclose medical information to contact you as a reminder
that you have an appointment for treatment or medical care at the hospital.
Ø
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.
Ø
Health-Related Benefits
and Services. We may use
and disclose medical information to tell you about health-related benefits or
services that may be of interest to you.
Ø
Fundraising Activities.
We may use medical information about you to contact you in an effort to
raise money for the hospital and its operations.
We may disclose medical information to a foundation related to the
hospital so that the foundation may contact you in raising money for the
hospital. We only would release
contact information, such as your name, address and phone number and the dates
you received treatment or services at the hospital.
If you do not want the hospital to contact you for fundraising efforts,
you must notify Harold L. Krueger, Jr. CEO, Chadron Community Hospital and
Health Services, 821 Morehead St. Chadron, NE. 69337, in writing.
Ø
Hospital Directory.
We may include certain limited information about you in the hospital
directory while you are a patient at the hospital.
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.
Ø
Individuals Involved in
Your Care or Payment for Your Care.
We may release medical information about you to a friend or family member
who is involved in your medical care. We
may also give information to someone who helps pay for your care.
We may also tell your family or friends your condition and that you are
in the hospital. In addition, we
may disclose medical information about you to an entity assisting in a disaster
relief effort so that your family can be notified about your condition, status
and location.
Ø
Research.
Under certain circumstances, we may use and disclose medical 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 medical information, trying to balance the research needs with patients'
need for privacy of their medical information.
Before we use or disclose medical information for research, the project
will have been approved through this research approval process, but we may,
however, disclose medical information about you to people preparing to conduct a
research project, for example, to help them look for patients with specific
medical needs, so long as the medical information they review does not leave the
hospital. 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 at the hospital.
Ø
As Required By Law.
We will disclose medical information about you when required to do so by
federal, state or local law.
Ø
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.
SPECIAL SITUATIONS
Ø
Organ and Tissue
Donation. If you are an
organ donor, we may release medical 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.
Ø
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.
Ø
Workers' Compensation.
We may release medical information about you for workers' compensation or
similar programs. These programs
provide benefits for work-related injuries or illness.
Ø
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 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.
Ø
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.
Ø
Lawsuits and Disputes.
If you are involved in a lawsuit or a dispute, 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
the dispute, but only if efforts have been made to tell you about the request or
to obtain an order protecting the information requested.
Ø
Law Enforcement.
We may release medical information if asked to do so by a law enforcement
official:
·
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.
Ø
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 of the hospital to
funeral directors as necessary to carry out their duties.
Ø
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.
Ø
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.
Ø
Inmates.
If you are an inmate of a correctional institution or under the custody
of a law enforcement official, we may release medical information about you to
the correctional institution or law enforcement official.
This release would be necessary (1) for the institution to provide you
with health care; (2) to protect your health and safety or the health and safety
of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING
MEDICAL INFORMATION ABOUT YOU.
You have the
following rights regarding medical information we maintain 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 Medical Records Department, Chadron Community Hospital
and Health Services, 821 Morehead St. Chadron, NE. 69337.
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.
Ø
Right to Amend.
If you feel that medical 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 or for the hospital. To
request an amendment, your request must be made in writing and submitted to The
Medical Records Department, Chadron Community Hospital and Health Services, 821
Morehead St. Chadron, NE. 69337. In
addition, you must provide a reason that supports your 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 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.
Ø
Right to an Accounting
of Disclosures. You have
the right to request an "accounting of disclosures."
This is a list of the disclosures we made of medical information about
you. To request this list or
accounting of disclosures, you must submit your request in writing to The
Medical Records Department, Chadron Community Hospital and Health Services, 821
Morehead St. Chadron, NE. 69337. Your request must state a time period which may not be longer
than six years and may not include dates before February 26, 2003.
Your request should indicate in what form you want the list (for example,
on paper, electronically). The
first list you request within a 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.
Ø
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 about
a surgery you had.
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.
To request restrictions, you must make your request in writing to The
Medical Records Department, Chadron Community Hospital and Health Services, 821
Morehead ST. Chadron, NE. 69337. 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.
Ø
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 or
by mail. To request confidential communications, you must make your request in
writing to The Medical Records Department, Chadron Community
Hospital and Health Services, 821 Morehead St. Chadron, NE. 69337.
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.
Ø
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
ma you obtain a copy of this notice at our
website, www.chadronhospital.com
To
obta To obtain a paper copy of this notice, write
to Privacy Administration, Chadron
Community Hospital and Health Services. 821 Morehead St. Chadron, NE. 69337
CHANGES TO THIS NOTICE
Ø
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
receive in the future. We will post a copy of the current notice in the hospital.
The notice will contain on the first page, in the top right-hand corner,
the effective date. In addition, each time you register at or are admitted to the
hospital for treatment or health care services as an inpatient or outpatient, we
will offer you a copy of the current notice in effect.
COMPLAINTS
If you believe your
privacy rights have been violated, you may file a complaint with the hospital or
with the Secretary of the Department of Health and Human Services.
To file a complaint with the hospital, contact Harold L. Krueger, Jr.
CEO, Chadron Community Hospital and Health Services, 821 Morehead St. Chadron,
NE. 69337. 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 use or 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.
***************
The final HIPAA privacy rules prohibit the notice and consent from being
combined into a single document. The
consent form is combined with the notice in this model document for convenience
only.
MODEL HIPAA CONSENT
Chadron Community
Hospital Patient Consent
Form
Our Notice of Privacy Practices provides information about
how we may use and disclose protected health information about you.
You have the right to review our notice before signing this consent.
As provided in our notice, the terms of our notice may change.
If we change our notice, you may obtain a revised copy by viewing it on
the internet or asking for a hard copy at Chadron Community Hospital and Health
Services.
You have the right to request that we restrict how
protected health information about you is used or disclosed for treatment,
payment or health care operations. We
are not required to agree to this restriction, but if we do, we are bound by our
agreement.
By signing this form, you consent to our use and disclosure
of protected health information about you for treatment, payment and health care
operations. You have the right to
revoke this consent, in writing, except where we have already made disclosures
in reliance on your prior consent.
Return to top
|
