Stanton County Hospital Notice of Privacy Practices

(Revised June 2015; Effective July 2015)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE  USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY.

SCH maintains client records consisting of personal, financial, social, and medical information. This information is used for diagnosis and treatment and for healthcare operations. The Health Insurance Portability and Accountability Act (“HIPAA”) establishes Privacy Rules that govern the  uses and disclosures of this information as do certain Kansas statues and regulations. We will not use or disclose health information about you without your consent or authorization, except as described in this notice or otherwise required or allowed by law. SCH 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.

SCH is required by law to maintain the privacy of protected health information, to provide individuals with notice of its legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.

USES AND DISCLOSURES OF HEALTH INFORMATION

Routine Types of Disclosures

• Treatment of client: for use by a physician, nurse or other member of your healthcare team to determine the best course of treatment for you. Healthcare providers will respond to clients’ voice mail with return calls and may leave messages.
• Third-party payers (insurance companies and governmental funding agencies): for use in payment collection and may include the diagnosis, treatment received, and date of treatment. (K.S.A. § 65-5603)
• Health professionals or subsequent healthcare provider: to assist in your care after you are no longer being treated by this facility or in addition to this facility. Contacts with referring healthcare professionals and pharmacies if indicated.
• Officers of the court: When treatment is a requirement of the court, health information will be disclosed to the appropriate agencies as required by law.
• To medical personnel when a medical condition poses an immediate threat to the health of the client and/or emergency medical intervention is warranted.
• Conducting quality assessment and improvement activities.
• Disclosures about certain victims of abuse, neglect, or domestic violence: SCH  may  be required to disclose protected health information to comply with Kansas’  mandatory child abuse and elder abuse reporting laws. SCH may also be permitted to disclose protected health information about certain victims of abuse, neglect, or domestic violence.
• Disclosures in judicial and administrative proceedings: SCH may be required, or permitted, to disclose PHI in response to a court order, grand jury subpoena, or other types of legal proceedings.
• Disclosures for certain law enforcement purposes: SCH may be required, or permitted, to disclose PHI to a law enforcement official engaged in a lawful investigative or legal purpose.
• Disclosures to Avert a Serious Threat to Health or Safety: SCH may, consistent  with  applicable law and standards of ethical conduct, use or disclose protected health information, if SCH believes in good faith that such information is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. SCH may also disclose protected health information if necessary for law enforcement authorities to identify and apprehend an individual.
• Disclosures about Crimes on SCH’s premises: SCH may use and disclose PHI that SCH believes, in good faith, constitutes evidence of criminal conduct that occurred on SCH’s premises.
• Disclosures about Crime Victims: SCH may use and disclose PHI in response to a law enforcement official’s request for information about an individual that is, or is suspected to be, a victim of a crime if certain conditions are met.
• Uses and Disclosures for Specialized Governmental Functions: SCH may use and disclose protected health information for specialized governmental and military purposes as permitted  or required by law.
• Uses and Disclosures for Workers’ Compensation Purposes: SCH may use and disclose PHI to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.
• Uses and Disclosure for Public Health Purposes and/or to Health Oversight Agencies: SCH  may use and disclose PHI for certain public health purposes or to agencies that oversee the healthcare system, such as the Kansas State Board of Nursing or the Kansas State Board of Healing Arts.
• Uses and Disclosures of PHI of Deceased Persons: SCH may use or disclose PHI about deceased persons to certain law enforcement officials, coroners, medical examiners, or funeral directors.
• Uses and Disclosure for Organ and Tissue Donation: SCH may use or disclose PHI to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation/transplants.
• Uses and Disclosures for Research: SCH may use or disclose PHI for research purposes if it meets very specific conditions.
• Uses and Disclosures of De-identified PHI or Limited Data Sets: In very  limited  circumstances, SCH may disclose de-identified (i.e. unidentifiable) PHI or PHI in limited data sets.
• Uses and Disclosures for Publication in a Facility Directory: SCH may, with your consent, disclose limited information for publication in a facility directory.
• Uses and Disclosures to Friends, Family Members, and Other Individuals: Using its best judgment, SCH may disclose to a family member, other relative, or to a close personal friend, health information relevant to that person’s involvement in your care or payment related to your care.
• Uses and Disclosures to Business Associates: SCH may use and disclose information to its Business Associates, who assist SCH with its operations.

Non-Routine Types of Disclosures

The items listed above are examples of uses and disclosures that may be made without your written authorization. Other uses and disclosures will be made only with your written authorization.

YOUR RIGHTS UNDER THE FEDERAL PRIVACY STANDARD

Although health records about you are SCH’s property, you have certain rights with regard to the information contained therein as follows:

You have the right to obtain a copy of this Notice of Information Practices. The Notice is  available to you in paper form and is posted on our website at www.stantoncountyhospital.com. Upon request, SCH will also provide you with a paper copy of this Notice, even if you have elected to receive the notice electronically.

You have the right to receive confidential communications of protected health information as provided by 45 C.F.R. § 164.522(b), as applicable.

You have the right to inspect and obtain a copy of health information about you upon written request. This right is not absolute and in certain situations, we can deny access if access might cause harm to the client or another individual. You do not have a right to access information in our records that was generated by an entity other than the SCH.

In other situations, when access to health information is denied, SCH will inform you of the reason for denying access and how to seek a review of that decision. The reviewable grounds for denial include but are not limited to:

• The access is reasonably likely to endanger the life or physical safety of the individual or another person, as determined by a qualified health professional.
• The health information makes reference to another person and such information is likely to cause substantial harm to the other person, as determined by a qualified health professional.
• The request is made by the individual’s designee and providing the information to the designee is likely to cause substantial harm to the individual or another person, as determined by a qualified health professional.

For these reviewable grounds, the Administrator will review the decision of the provider denying access, and provide the client a written explanation of the reason(s) for denial within 60 days.

If you request an electronic copy of protected health information that is maintained electronically in one or more designated record sets, SCH will provide you access to the electronic information in electronic form and format request, if it is readily producible or, if not, in a readable electronic form and format agreed to by you and SCH.

You have the right to request a correction or amendment to health information about you. We  do not have to grant the request if the record was not created by SCH.  In such instances, you must  seek correction or amendment from the agency creating the record. If they correct or amend the information, we will file the change in our record. We do not have to grant the request if the record is accurate and complete, or if the record is not available to you as described immediately above. If your request for correction or amendment is denied, SCH will inform you of the reason for denying access. If the request for correction or amendment to the record is granted, the change will be made to our record, and the correction/amendment distributed to those you identify to us as needing the  information. When appropriate, the correction or amendment may be distributed to other entities, as defined in the Uses and Disclosures section of this Notice.

You have the right to request restriction on uses and disclosures of health information about you for treatment, payment, and health care operations, and communications by alternate means. “Health care operations” consist of activities that are necessary to carry out the operations of SCH, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted or required under 164.502(a)(2)(i) (disclosures to you), 164.510(a) (for facility directories, but note that you have the right to object to such uses), or 164.512 (uses and disclosures  not requiring a consent or an authorization).  The latter uses and disclosures include, for example,  those required by law like mandatory reporting of child and adult abuse, and in those cases, you do not have a right to request restriction. The Consent to use and disclose individually identifiable health information form includes an option to request restriction. We do not, however, have to agree to the restriction. If the restriction is granted, we will adhere to it unless you request otherwise or we give  you advance notice. You may also ask us to communicate with you by alternate means and, if the method of communication is reasonable, we must grant the alternate communication request. Refer to the consent form.

You have the right to request a restriction of disclosure of certain protected health information about you to a health plan. You may request SCH not to disclosure protected health information about you to a health plan if: (1) the disclosure is for the purpose of carrying out payment or  healthcare operations and is not otherwise required by law; and (2) the protected health information pertains solely to a healthcare item or service for which you, or person other than the health plan on behalf of the individual, has paid the covered entity in full.

You have the right to obtain an accounting of “non-routine” uses and disclosures, other than those for treatment, payment, and health care operations. However, we do not need to provide an accounting of uses and disclosures made prior to 4-14-2003 and for:

• The facility directory, or to persons involved in the individual’s care as provided in 164.510 (uses and disclosures requiring an opportunity for the individual to agree or object, including notification to family members, personal representatives, or others responsible for the care of the individual).
• National security or intelligence purposes under 164.512(k)(2) (disclosures not requiring consent, authorization, or an opportunity to object, see chapter 16).
• Those made to correctional institutions or law enforcement officials under 164.512(k)(5) (disclosures not requiring consent, authorization, or an opportunity to object).

After receipt of a valid, written request for non-routine accounting, we will provide the accounting within 60 days. The accounting will include the date of each disclosure, the name and address of the entity who received the health information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure that informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization, or a copy of a written request for disclosure.

You have the right to be notified following a breach of unsecured protected health information.

You have the right to revoke your consent or authorization to use or disclose health information in accordance with 45 C.F.R. § 164.508(b)(5), except to the extent that we have already taken action in reliance on the consent or authorization.