Privacy
ALL SAINTS
CATHOLIC NURSING HOME
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.
Please contact the Privacy Officer at (904) 772-1220 ext. 238 if
you have any questions regarding this notice.
**This notice is effective April 14, 2003.
If you believe your privacy rights have been violated, you can
file a complaint with the Assistant Controller, CPA/Privacy Officer or with the Secretary of Health and Human Services. There
will be NO retaliation for filing a complaint.
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
Each time you visit a hospital, physician, or other healthcare
provider, a record of your visit is made. Typically, this record
contains your symptoms, examination and test results, diagnoses,
treatment and a plan for future care or treatment. This information,
often referred to as your health or medical record, serves as a:
1) basis for planning your care and treatment; 2) means of
communications among the many health professionals who contribute to
your care; 3) legal document describing the care you received; 4)
means by which you or a third party payer can verify that services
billed were actually provided; 5) a tool in educating health
professionals; 6) a source of data for medical research; 7) a source
of information for public health officials charged with improving
the health of the nation; 8) a source of data for facility planning
and marketing and a tool with which we can assess and continually
work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health
information is used helps you to:
ensure its accuracy; better understand who, what, when, where and
why others may access your health information; make more informed
decisions when authorizing disclosure to others.
YOUR HEALTH INFORMATION RIGHTS:
Although your health record is the physical property of the
healthcare practitioner or facility that compiled it, the
information belongs to you. You have the right to:
1) Request a restriction on certain uses and disclosures of
your information as provided by 45 CFR 164.522. You have the right
to request a limitation on the health information we use or disclose
about you for treatment, payment or healthcare operations. You also
have the right to request a limit on the health information we
disclose about you to someone, such as a family member or friend,
who is involved in your care or in the payment of your care. For
example you could ask that we not disclose information regarding a
particular treatment that you received. 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 emergency treatment to
you. To request restrictions, you must make your request in writing
to Admissions. 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, to a family
member).
2) Obtain a paper copy of the notice of information
practices upon request; Inspect and copy your health record as
provided for in 45 CFR 164.524 (Exception:
Psychotherapy Notes). To inspect and copy your health record
(Generally this includes medical and billing records) you must
submit your request in writing to the Medical Records Department. 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. In certain limited circumstances we may deny access to your
health information. You may request that the denial be reviewed.
Another licensed health care professional selected by our facility
will review your request and the denial. The person conducting the
review will not be the person who initially denied your request. We
will comply with the outcome of this review;
3) Amend your health record as provided in 45 CFR 164.528
To obtain a request to amend your health information, your request
must be made in writing and submitted to the Director of Medical
Records. In addition, you must provide us with a reason that
supports your request. We may deny your request if it is not in
writing or does not include a reason to support the request.
Additionally, we may deny your request if you ask us to amend
information that: 1) Was not created by us, 2) Is not part of the
health information kept by or for our facility, 3) Is not part of
the information which you would be permitted to inspect and copy, 4)
Is accurate and complete. 4) Obtain an accounting of disclosures of
your health information by alternative means or at alternative
locations. This accounting will not include disclosures made for
purposes of treatment, payment, or health care operations. To
request an accounting of disclosures, your request must be in
writing, submitted to the Medical Records Department. Your request
must state a time period, which may not be longer than six (6) years
prior to the date of your request and may not include dates before
April 14, 2003. Your request should indicate in what form you want
to receive the accounting (paper, electronic). The first accounting
you request within a 12 month period will be free. For additional
accountings, we may charge you for the costs of providing the
accounting. 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;
5) Revoke your authorization to use or disclose health
information except to the extent that action has already been taken.
OUR RESPONSIBILITIES:
This organization is required to:
Maintain the privacy of your health information; provide you with
a notice as to our legal duties and privacy practices with respect
to information we collect and maintain about you; abide by the terms
of this notice; notify you if we are unable to agree to a requested
restriction; accommodate reasonable requests you may have to
communicate health information by alternative means or at
alternative locations. We reserve the right to change our practices
and to make the new provisions effective for all protected health
information we maintain. Should our information practices change, we
will mail a revised notice to the address you’ve supplied to us and
post a copy of the current notice in our facility. The first page of
the notice contains the effective date and any dates of revision.
We will not use or disclose your health information without your
authorization, except as described in this notice.
To obtain a paper copy of this notice, contact Admissions.
EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE
OPERATIONS:
We will use your health information for treatment. For example:
Information obtained by a nurse, physician, or other member of your
healthcare team will be recorded in your record and used to
determine the course of treatment that should work best for you. We
will also provide your physician or a subsequent healthcare provided
with copies of various reports that should assist him/her in
treating you.
We will use your health information for payment. For example; A
bill may be sent to you or a third party payer. The information on
or accompanying the bill may include information that identifies
you, as well as your diagnosis, procedures and supplies used. We may
also tell your health plan about a treatment you are going to
receive in order to obtain prior approval for the services or to
determine whether your health plan will cover the payment.
We will use your health information for regular health
operations. For example:
Members of the medical staff, the risk or quality improvement
manager, or members of the quality improvement team may use
information in your health record to evaluate the performance of our
staff in caring for you. We may disclose your health information to
physicians, nurses, nursing assistants, rehabilitation therapy
specialists, technicians, and other personnel for review and
learning purposes. This information will then be used in an effort
to continually improve the quality and effectiveness of the
healthcare and service we provide.
We may use or disclose your health information to a health
oversight agency that is authorized by law to conduct health
oversight activities. These oversight activities may include
licensure and certification surveys. These activities are necessary
for the government to monitor the persons or organizations that
provide health care to individuals and to ensure compliance with
applicable state and federal laws and regulations.
OTHER USES OR DISCLOSURES:
BUSINESS ASSOCIATES: There are some services provided in our
organization through contracts with business associates. Examples
include Pharmacy and Dietary consulting services. When these
services are contracted, we may disclose your health information to
our business associate so that they can perform the job we’ve asked
them to do, and in some cases bill you or your third party payer for
services rendered. We require the business associate to
appropriately safeguard and protect your information.
DIRECTORY: Unless you notify us that you object, we will use your
name, location in the facility, general condition, and religious
affiliation for directory purposes. This information may be provided
to members of the clergy and, except for religious affiliation to
other people who ask for you by name.
NOTIFICATION: We may use or disclose information to notify or
assist in notifying a family member, personal representative, or
another person responsible for your care, your location, and general
condition.
COMMUNICATION WITH FAMILY: Health professionals, using their best
judgment, may disclose to a family member, other relative, close
personal friend or any other person you identify, health information
relevant to that person’s involvement in your care or payment
related to your care.
RESEARCH: We may disclose information to researchers under
certain limited circumstances, when their research has been approved
by a special approval process. The research proposal and established
protocols would be reviewed to ensure the privacy of your health
information. We may however use or disclose your health information
to individuals preparing to conduct the research project in order to
assist them in identifying residents with specific health care needs
who may qualify to participate in the research project. Any use or
disclosure of your health information that may be done for the.
purpose of identifying qualified participants will be conducted
onsite at our facility. In most instances, we will ask for your
specific permission to use of disclose your health information if
the researcher will have access to your name, address or other
identifying information.
CORONERS, MEDICAL EXAMINERS, OR FUNERAL DIRECTORS: We may use or
disclose your health information to a coroner, medical examiner or
funeral director for the purpose of identifying a deceased
individual or to determine the cause of death, consistent with
applicable law to carry out their duties.
ORGAN PROCUREMENT ORGANIZATIONS: If you are an organ donor,
consistent with applicable law, we may disclose health information
to organ procurement organizations or other entities engaged in the
procurement, banking, or transplantation of organs for the purposes
of tissue donation and transplant.
MARKETING: We may contact you to provide appointment reminders or
information about treatment alternatives or other health related
benefits and services that may be of interest to you.
FUND RAISING: We may contact you as part of a fund-raising
effort.
FOOD AND DRUG ADMINISTRATION (FDA): We may disclose to the FDA
health information relative to adverse events with respect to food,
supplements, product and product defects or post marketing
surveillance information to enable product recalls, repairs or
replacement.
WORKERS COMPENSATION: We may disclose health information to the
extent authorized by and to the extent necessary to comply with laws
relating to workers compensation when your health condition arises
out of a work related illness or injury, or other similar programs
established by law.
PUBLIC HEALTH: As required by law, we may disclose your health
information to public health or legal authorities charged with
preventing or controlling disease, injury or disability. Examples
include: To report deaths; To report suspected or actual abuse,
neglect, or domestic violence; To report adverse reactions to
medications or problems with health care products; To notify an
individual who may have been exposed to disease or may be at risk
for spreading or contracting a disease or condition.
CORRECTIONAL INSTITUTION: Should you be an inmate of a
correctional institution, we may disclose to the institution or
agents thereof, health information necessary for your health, and
the health and safety of other individuals.
LAW ENFORCEMENT: We may disclose health information for law
enforcement purposes as required by law, or in response to a valid
subpoena, court order, warrant, summons or similar lawful process.
We may disclose health information in emergency situations,, to
report a crime or criminal activity at our facility.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use or
disclose your health information when necessary to prevent a serious
threat to the health or safety of you or other individuals. Any such
use or disclosure would be made solely to the individual(s) or
organization(s) that have the ability and/or authority to assist in
preventing the threat.
Federal law makes provision for your health information to be
released to an appropriate health oversight. agency, public health
authority or attorney, provided that a workforce member or business
associate believes in good faith that we have engaged in unlawful
conduct or have otherwise violated professional or clinical
standards and are potentially endangering one or more patients,
workers or the public.
My signature below indicates that I have been provided a copy of
the notice of privacy practices.
_____________________________________ _________________
Signature of Resident or Legal Representative Date
If signed by legal representative, relationship to the
patient __________________________________________
