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Mt. San Rafael Hospital

Notice of Privacy Practices

Effective Date: October 2009
This Notice describes how 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 Hospital Privacy Official by dialing 719-846-9213.

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, a plan for future care, and billing-related information. This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel, agents of the hospital, or your personal doctor. Your personal doctor may have different policies or notices regading the doctor's use and disclosure of your health information created in the doctor's office or clinic.

Our Responsibilities

We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice.

Users and Disclosures

How We May Use And Disclose Medical Information About You

The following categories describe examples of the way we use and disclose health information:

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, 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. Different departments of the hospital may also share health information about you in order to coordinate the different things you need, such as prescriptions, lab work, meals, and x-rays.

We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you're discharged from the hospital.

For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company, or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to determine whether your plan will cover it.

For Health Care Operations: Members of the medical staff and/or Quality Improvement Team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. For example, we may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses, and students for educational purposes. We may combine health information we have with that of other hospitals to see where we can make improvements. We may remove information that identifies you from this set of health information to protect your privacy.

We may use and disclose health information:

To business associates we have contracted with to perform the agreed upon service and billing for it;
To remind you that you have an appointment for medical care;
To assess your satisfaction with our services;
To tell you about possible treatment alternatives;
To tell you about health-related benefits or services;
To contact you as part of fundraising efforts;
To inform Funeral Directors consistent with applicable law;
For population-based activities relating to improving health or reducing healthcare costs; and
For conducting training programs or reviewing competence of healthcare professionals.

When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voicemail.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include physician services in the emergency department and readiology, certain laboratory tests and other diagnostic services. When these services are contracted, we may disclose your health information to our business associates so they can perform the job we've asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

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, good, etc.), and your religious affiliation. This information may be provided to members of the clergy and, except for your religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the hospital directory please request the Opt Out Form from the admission staff.

Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so your family can be notified about your condition, status, and location.

Future Communications: We may communicate to you via newsletters, mailings or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities in which our hospital participates.

Organized Healthcare Arrangement: This hospital and its medical staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment, and healthcare operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.

As Required By Law: We may also use and disclose health information for the following types of entities, including but not limited to:

Food and Drug Administration
Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
Correctional Institutions
Workers Compensation Agents
Organ and Tissue Donation Organizations
Military Command Authorities
Health Oversight Agencies
Funeral Directors, Coroners, and Medical Directors
National Security and Intelligence Agencies
Others as deemed by Hospital Policy and state or federal laws

Colorado-Specific Requirements: Colorado has separate privacy laws that may apply additional legal requirements. If Colorado's privacy laws are more protective of your rights, Colorado law will preempt federal law.

Law Enforecement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Your Health Information Rights

Although your health record is the physical property of the hospital which compiled it, you have the Right to:

Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. We may deny your request to inspect and copy in certain, very limited circumstances. If you are denied access to health information, you may request the denial be reviewed. Another licensed healthcare 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.

Amend: If you feel that health information we have on file 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. We may deny your request for an amendment and, if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we make of your health information for purposes other than treatment, payment, or healthcare operations where an authorization was not required.

Request Restrictions: You have the right to request a restriction or 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 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. A request must be made in writing and addressed to the Health Information Department. 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 with emergency treatment.

Request Confidential Communications: You have the right to request we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you at work instead of your home. The hospital will grant reasonable requests for confidential communications only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

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.

To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

Changes to This Notice

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the hospital and include the effective date. In addition, each time you register at or are admitted to the hospital for treatment or healthcare 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 by following the process outlined in the hospital's Patient Rights documentation. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Health Information

Other uses and disclosures of health 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 health 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 health 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.

Hospital Privacy Officer
Telephone Number: (719) 846-9213