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HIPAA
Effective Date: 04.14.2003
Revised Date: 02.24.2009
Revised Date: 07.2011
JOINT 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.
If you have any questions specifically about this Joint Notice, please contact:
Rutherford Regional Health System Privacy Officer
288 South Ridgecrest Avenue
Rutherfordton, NC 28139
Phone: (828) 286-7292
E-mail: Privacy.Officer@rutherfordregional.com
OUR LEGAL DUTY TO SAFEGUARD YOUR MEDICAL INFORMATION
Under federal law, your Protected Health Information (PHI) has been determined to be confidential, requiring appropriate protections. Your PHI includes information about (1) your treatment - symptoms, test results, diagnosis, etc., (2) payment activities - billing, insurance information, etc., and (3) health care operations - administrative oversight activities concerning the quality of care and services you receive, etc.
We are required to provide you with this Joint Notice of Privacy Practices (Joint Notice). It outlines our privacy policies and practices and explains how, when, and why we use and disclose your PHI. With some specific exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the intended purpose of the use or disclosure.
We are also required to make a good faith effort to obtain your written acknowledgement that you are in receipt of our Joint Notice.
WHO WILL FOLLOW THIS JOINT NOTICE
The terms of this Joint Notice apply to Rutherford Regional Health System (RRHS) and to the services provided by its clinically integrated health care system made up of Rutherford Regional Medical Center, its medical staff while in the hospital, and all RRHS entities and programs regardless of site or location.
This Joint Notice describes the policies and practices governing how your PHI is gathered, utilized, and maintained, not only by RRHS, but also by the physicians and other licensed professionals rendering your care. (NOTE: Your personal physician may have different notices and policies in force at their private office or clinic that govern their use and disclosure of your PHI).
Specifically, our policies and practices regarding your PHI will be followed by:
- Any health care provider authorized to enter information into your health care record.
- All employees and staff of RRHS.
- All others that have been requested by RRHS to perform services on behalf of RRHS.
- Any member of a volunteer group that is allowed to assist you while you are in the hospital.
- Any student who, as part of their approved clinical program, is permitted to access your healthcare record
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we, or our business associates acting on our behalf, may use and disclose medical information without further written authorization from you.
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.
ROUTINE SITUATIONS
In order to efficiently coordinate the treatment, payment, and health care operations aspects of your care, we may disclose your PHI with others involved in your care in any format that we determine is secure and expeditious, e.g., verbally, electronically, via fax, and/or in paper form for the following:
For Treatment
We may use and disclose your PHI to provide you with medical treatment or services. For example, doctors, nurses, technicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information 1) to other health care providers who are participating in your treatment, e.g. to pharmacists who are filling your prescriptions, home health agencies, etc., 2) to people outside the hospital who may be involved in your medical we contact that will provide necessary services related to your care.
For Payment
We may use and disclose your PHI so that the treatment services you received may be appropriately billed and payment received from you, an insurance company, or other third party. For example, we may need to give your health plan specific information about your care so that your health plan can determine the correct payment amount. We may also tell your health plan about a recommended treatment for you in order to receive their prior approval or to determine whether or not they will cover the treatment.
For Health Care Operations
We may use and disclose your PHI for the purpose of health care operations that are necessary to ensure that all of our patients receive quality care and services. For example, we may use your PHI to review our treatment and services and to evaluate the performance of our staff in caring for you. We may disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for quality review and learning purposes. We may also remove information that identifies you from aggregate data that is to be used to study health care trends and health care delivery alternatives without learning who the specific patients are.
Appointment Reminders
We may use and disclose your PHI to contact you as a reminder that you have an appointment for treatment or medical care or to gather information from you about the quality of the medical care you received and/or the manner in which that care was provided.
Treatment Alternatives
We may use and disclose your PHI 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 your PHI to tell you about health-related benefits or services that may be of interest to you.
Hospital Directory
Unless you object, we may include certain limited PHI about you in the hospital directory while you are a patient. This information may include your name, location in the hospital, your general condition (e.g., good, stable, etc.), and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name, whether by phone or in person. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends, and clergy can contact and/or visit you in the hospital and generally know how you are doing. Should you so desire, you may request not to be included in the facility directory in order to limit either of these disclosures.
Individuals Involved in Your Care or Payment for Your Care
Unless you object, we may release your PHI to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. 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.
DISCLOSURE IN SPECIAL SITUATIONS
As Required By Law. We will disclose your PHI when required to do so by federal, state, or local law.
Fundraising Activities
We may, on a limited basis, disclose your PHI to Rutherford Hospital Foundation to secure contributions for RHI and the services it offers to the community. In such cases, we would limit your PHI to demographic information only, such as your name, address, and phone number and the dates you received treatment or services. We would not release information which would identify the reasons you were receiving treatment, e.g. diagnosis, etc. If you do not want the Rutherford Hospital Foundation to receive your contact information for fundraising purposes, you may so notify the RRHS Privacy Officer in writing.
Research
In limited circumstances, we may use and disclose your PHI for research purposes. For example, a research project may involve comparing the health status and recovery of all patients who received one medication to those who, for the same condition, received another. In all cases where your specific authorization has not been obtained, your privacy will be protected by the strict confidentiality requirements applied by an independent Institutional Review Board (or other officially recognized independent privacy board) that oversees the research that is conducted at RHI.
To Avert a Serious Threat to Health or Safety
We may use and disclose your PHI 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 such a threat.
Organ and Tissue Donation
If you are an organ donor, we may disclose your PHI to the 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 disclose your PHI as required by military command authorities. We may also release the PHI about foreign military personnel to the appropriate foreign military authority.
Worker’s Compensation
We may disclose your PHI for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks
We may disclose your PHI for public health activities. These activities generally include the following:
- to prevent or control disease, injury, or disability;
- to report births, deaths, and immunizations;
- to report abuse or neglect or child in need of protective services;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- 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.
Victims of Abuse
We may disclose your PHI 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 your PHI 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 your PHI 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 and only as permitted by State law.
Law Enforcement
We may disclose your PHI as permitted by State law if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons, or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the hospital; and
- 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 disclose your PHI 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 disclose your PHI 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 your PHI to authorized federal officials so they may 1) provide protection to the President, other authorized persons or foreign heads of state or 2) conduct special investigations related to such protection.
Inmates
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to the correctional institution or law enforcement official. This disclosure of information 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.
SPECIAL PROTECTIONS
In some cases, North Carolina or Federal law may provide additional protection for your PHI. In the following situations, we will follow the practices specified in this section before using or disclosing the PHI affected in accordance with the remainder of this Joint Notice.
Treatment for Drug Dependence
If you request treatment and rehabilitation for drug dependence, we will not disclose your name to any police officer or other law-enforcement officer unless you consent to our sharing of it.
Communicable Diseases
If you suffer from a communicable disease (for example, tuberculosis, syphilis or HIV/AIDS), information about your disease will be treated as confidential. We will only release such information under the following circumstances: 1) with your written authorization; 2) for statistical purposes in a way that does not identify you; 3) to other health care personnel providing you with treatment; 4) to protect the public health and as provided by regulation; 5) to report as required by law; 6) pursuant to a subpoena or court order; 7) as otherwise specifically authorized or required by law.
Mental Health Services
One or more of the facilities covered by this Joint Notice may be required to keep confidential information relating to mental health services, including treatment for mental illness, developmental disability or substance abuse. Such information will not be disclosed without your written consent, except in certain circumstances, potentially including the
following: 1) to individuals within our facility involved in your treatment or habilitation, 2) to other facilities when necessary to coordinate appropriate and effective care, treatment or habilitation, 3) to your next of kin upon your request if the next of kin plays a legitimate role in your treatment, 4) when in our opinion there is an imminent danger to the health or safety of another individual, 5) to a provider of support services, 6) to a State or governmental agency when we believe you may be eligible for financial benefits through such agency, 7) to report suspected neglect or abuse as required by law, 8) to make other reports to the State as required by law, 9) upon court order, 10) to a court of competent jurisdiction that has ordered a mental examination of you as a criminal defendant, 11) to the Attorney General’s office when the information is necessary for performance of the statutory responsibilities of the Attorney
General, 12) to our attorney if such information is relevant to litigation involving our facility, and 13) to an attorney upon your written request. Furthermore, if we determine that the disclosure is in your best interest, we may 1) disclose the fact of your admission or discharge to your next of
kin, and 2) disclose confidential information for purposes of filing a petition for involuntary commitment or a petition for adjudication of incompetency. To the extent that any PHI can identify you as a substance abuse patient, such information may be entitled to stricter protection, and we will comply with any applicable law restricting the disclosure of such information.
OTHER USES OF MEDICAL INFORMATION
All other uses and disclosures of your PHI not covered by this Joint Notice or the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose your PHI for specific purposes, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the purposes covered by your written authorization. You understand that we are unable to retract any disclosures we have already made with your authorization.
YOUR RIGHTS REGARDING YOUR PHI
Right to Inspect and Copy
You have the right to inspect and copy your PHI that is a part of our Designated Record Set - records that are used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy your Designated Record Set, you must submit your request in writing to:
Director - Medical Records Department
Rutherford Regional Health System
288 South Ridgecrest Avenue
Rutherfordton, NC 28139
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 our privacy officer arrange for a review of that denial. Another licensed health care professional chosen by our privacy officer 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 any of the PHI 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 we keep the information. To request an amendment, you must submit your request in writing to:
Director - Medical Records Department (address noted, above). In addition, you must provide a reason that supports your request.
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:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the Designated Record Set kept by or for RRHS;
- Is not part of the information which you would be permitted to inspect and copy or
- Is accurate and complete.
We will inform you in writing for the reasons of the denial and describe your rights to file a written statement in disagreement.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures”. This is a list of the disclosures we have made of your PHI that were 1) not related to your treatment, payment or health care operations and certain other instances in which disclosure is permitted or 2) not authorized by you or your personal representative.
To request this list or accounting of disclosures, you must submit your request in writing to: Director - Medical Records Department (address noted, above). 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 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 PHI we use or disclose about you. You also have the right to request a limit on the PHI 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 grant your request. However, if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or in certain instances in which a full disclosure is legally required or permitted.
To request restrictions, you must make your request in writing to: Director - Medical Records Department (address noted, above). In your request, 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, 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 Director - Medical Records Department (address noted, above). We will not ask you the reason for your request and 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 Joint Notice
You have the right to a paper copy of this Joint Notice. You may ask us to give you a copy of this Joint Notice at any time. Even if you have agreed to receive this Joint Notice electronically, you are still entitled to a paper copy of this Joint Notice. You may obtain a copy of this Joint Notice at our website, www.myrutherfordregional.com. To obtain a paper copy of this Joint Notice, please contact the RRHS Privacy Officer (address and phone number noted on pg.1 of this document).
WHO MAY EXERCISE RIGHTS UNDER THIS NOTICE
In most situations, the rights set forth in this Joint Notice may be exercised by you or your personal representative on your behalf. If you are an unemancipated minor, the rights set forth in this Joint Notice may be exercised on your behalf by your parent or parents, or your legal guardian in most situations with some exceptions. For example, you have the right to consent to
services for the prevention, diagnosis and treatment of certain illnesses, including venereal disease and other diseases that must be reported to the State, pregnancy (except abortion), abuse of controlled substances or alcohol, and emotional disturbance, and therefore only you may exercise the rights set forth in this Joint Notice on your own behalf with respect to information pertaining to those illnesses. Abortion services do require the consent of a parent, legal guardian, or grandparent in some situations, absent a court order.
CHANGES TO THIS JOINT NOTICE
We reserve the right to change this Joint Notice and reserve the right to make the revised or changed Joint Notice effective for PHI we already have about you as well as such PHI we receive in the future. We will prominently post a copy of the current Joint Notice in public areas of RRHS and its affiliates. The Joint Notice will contain on the first page, in the top left-hand corner, its effective date.
COMPLAINTS CONCERNING PRIVACY RIGHTS VIOLATIONS
If you believe your privacy rights have been violated, you may file a formal complaint with RRHS and/or with the Secretary of the Department of Health and Human Services.
You may file a formal complaint concerning your privacy rights with RRHS by contacting the Privacy Officer at:
Rutherford Regional Health System Privacy Officer
288 South Ridgecrest Avenue
Rutherfordton, NC 28139
Phone: (828) 286-7292
E-mail: Privacy.Officer@rutherfordregional.com
You may file a formal complaint concerning your privacy rights with the U.S. Department of Health and Human Services at:
Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
(404) 562-7886 (Voice Phone)
(404) 331-2867 (TDD)
(404) 562-7881 (FAX)
www.hhs.gov/ocr/privacy
Please note that you may be asked to submit your complaint in writing. You will not be penalized for filing a complaint.
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