Athol Memorial Hospital
Quality healthcare close to home
HIPAA Notice of Privacy Practices
Effective Date: October 20, 2005
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.
If you have any questions about this notice, please contact the hospitals
Privacy Officer at the extension listed on the back of this pamphlet.
Who Will Follow This Notice:
This notice describes our facilitys practices and that of:
Any health care professional authorized to enter information into your chart.
All employees and medical staff Practice personnel.
Our Pledge Regarding Medical Information:
We understand that medical information about you and your health is personal. We
are committed to protecting medical information about you. We create a record of
the care and services you receive at this hospital. 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 generated by the
hospital, whether made by Hospital personnel or your doctor. This notice will
tell you about the ways in which we may use and disclose medical information
about you. We also describe your rights and certain obligations we have
regarding the use and disclosure of medical information.
Law to requires us:
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.
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we use and disclose
medical information. For each category of uses or disclosures we will explain
what we mean and try to give some examples. 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.
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, and technicians. We also may disclose medical information about
you to people outside the hospital who may be involved in your medical care.
For Payment. We may use and disclose medical information about you so that the
treatment and services you receive 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 so your health plan
will pay us for the services. 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.
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 facility should offer, what services are not needed, and whether
certain new treatments are effective. We may also disclose information to
doctors, nurses, technicians, 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.
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 in
our hospital.
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.
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.
Hospital Directory. Information may include your name, location in the
hospital, and your religious affiliation. This 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, if you identify a religious affiliation at the time of
registration. This is so your family, friends and clergy can visit you in the
hospital.
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 if you identify the individual as such. 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.
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 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.
As Required By Law. We will disclose medical information about you when
required to do so by federal, state or local law.
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:
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.
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.
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.
Public Health Risks. We may disclose medical information about you for public
health activities. These activities generally include the following:
o To prevent or control disease, injury or disability;
o To report births and deaths;
o To report child abuse or neglect;
o To report reactions to medications or problems with products;
o To notify people of recalls of products they may be using;
o 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;
o 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.
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.
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.
Law Enforcement. We may release medical information if asked to do so by a law
enforcement official:
o In response to a court order, subpoena, warrant, summons or similar process;
o To identify or locate a suspect, fugitive, material witness, or missing
person;
o About the victim of a crime if, under certain limited circumstances, we are
unable to obtain the person's agreement;
o About a death we believe may be the result of criminal conduct;
o About criminal conduct at the hospital; and
o 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.
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.
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.
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.
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 Health Information
Management 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.
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, and agreed to by you, 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.
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 the
hospital.
To request an amendment, your request must be made in writing and submitted to
the Health Information Management department. In addition, you must provide a
reason that supports your request and it should be a maximum of one (1) page.
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:
o Was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
o Is not part of the medical information kept by or for the hospital;
o Is not part of the information which you would be permitted to inspect and
copy; or
o Is accurate and complete.
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 Health Information Management department. 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.
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 with 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 Health
Information Management department. In your request, you must state (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.
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 Health Information management department. 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.
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.
You may obtain a copy of this notice at our website, www.atholhospital.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 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 the hospital, for treatment or health care services, 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 the Complaint Officer,
or any member of the Organizations HIPAA Committee listed on the back of this
pamphlet. 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.
Athol Memorial Hospital
HIPAA Compliance Committee:
978-249-3511
Complaint Officer, Chief Nursing Officer ext. 228
Corporate Compliance Officer, ext.106
President/ CEO, ext. 101
Human Resources Manager, ext. 226
Director of Health Information Management, ext. 137
Information Security, ext. 356
Privacy Officer, ext. 116
Patient Accounts Manager, ext. 363