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 ask to speak to our Privacy Officer.
This notice describes our hospital's practices and that of:
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 the 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 personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.
This notice will tell you about the ways in which the hospital 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.
We are required by law to:
Your protected health information may be used and/or disclosed for the following reasons:
Treatment - We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We may disclose medical information about you to doctors, nurses, technicians, home health care workers 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.
We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat you.
We may also disclose your protected health information to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, Area Agency on Aging, clergy or others we use to provide services that are part of your care. For example, we would disclose information about you, as necessary, to a home health agency to which you had been referred
Payment - Your protected health information will be used and disclosed to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations - Your protected health information will be used, as needed, to support the business activities of the hospital. These activities may include quality assessment, credentialing and licensing activities, marketing and fundraising activities and conducting or arranging for other business activities. For example, your name and address may be used to send you a newsletter about our facility and the services we offer. We may also use or disclose your demographic information and the dates that you received treatment at our facility, as necessary, in order to contact you for fundraising activities supported by our facility. If you do not want to receive these materials, contact our facility Privacy Officer to request that these materials not be sent to you. Upon this request, we will forward a form for you to sign so the hospital can keep it on file.
We may disclose certain information about you on our Hospital Directory while you are a patient at the hospital. The information may include your name, location in the hospital and 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 protected health information may also be disclosed for these purposes without your consent or authorization:
Uses and disclosures of protected health information based on your written authorization.
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that the hospital has taken an action in reliance on the use and disclosure indicated in the authorization.
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. This does not include psychotherapy notes. Your request to inspect or copy medical information must be in writing to our Privacy Officer. We will respond to your request within 60 days. We may charge you a small fee for the cost of copying and mailing the information. 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. 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. Your request for an amendment must be in writing to the Privacy Officer and you must provide a reason that supports your request. We will respond to your request in writing within 60 days. We may deny your request for an amendment if it is not in writing or does not include reason to support the request. We may also deny your request for the following reasons:
If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
Right to an Accounting of Disclosures - You have the right to request a list of certain disclosures we have made of medical information about you. To request a list, you must put your request in writing. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should state how you want the list forwarded to you. The first list in a 12-month period will be free. For additional lists, we may charge a fee for providing the list.
Right to Request Restrictions - You have the right to request restrictions or limitations on the medical information we use or disclose about you for treatment, payment and healthcare 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. 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. You must request any restrictions in writing. You must tell us what information you want to limit, whether you want to limit our use, disclosure or both; and 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. Your request must be in writing and specify how or where you wish to be contacted. We will accommodate all reasonable requests.
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 at http://www.brookvillehospital.org.
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 also be available on the website, http://www.brookvillehospital.org , or you can contact the hospital to request a current copy. The notice will contain on the first page, in the 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.
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 at the Office for Civil rights, US Department of health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201. To file a complaint with the hospital, please ask for our Privacy Officer. All complaints must be 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 not able 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.
Revised: July 17, 2012