Seaside Healthcare, INC NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
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1 Seaside Healthcare, INC NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The law requires us to make sure that medical information that tells who you are is kept private. It also requires us to give you this notice of our legal duties and privacy practices to tell you what we do with the medical information about you. To better understand this law, you may want to read it. It is located in the Code of Federal Regulations, Title 45, Part 164. We have the right to change this notice and our privacy practices in the future. Any changes made will apply to all of the medical information we have about you at that time. If we make a change, we will put up a notice in our building. We will also give you a copy of the new notice if you ask for it. You can also read about these changes on the computer. We have this information on our website at HOW YOUR MEDICAL INFORMATION MAY BE USED: In general, we may use your medical information in four ways: To provide patient care to you. Your medical information may be used by the doctors, nurses and other professionals who are treating you. For example, your medical information is used to help them find out your problem and to decide the best way to treat you. Also, we may use your medical information to contact you to remind you of appointments, and to give you information about other treatment options, or other healthrelated benefits and services that may be of interest to you. However, when communicating appointment reminders, treatment options, or other related benefits and services that the hospital receives cash or cash equivalents for, you will be asked for your authorization. The hospital typically does not receive cash or cash equivalents for such reminders. To obtain payment. Your medical information may also be used by our business office to prepare your bill and process payments from you as well as from any insurance company, government program or other person who is responsible for payment. Also, we may use your medical information to raise funds for our organization. For our healthcare operations. Your medical information may be used to review the quality and appropriateness of the care you receive. We may also use your medical information to put together information to see how we are doing and to make improvements in the services and care we give you. In addition we may have students, trainees, or other health care personnel, as well as some non health care personnel, who come to our facility to learn under our guidance to practice or improve their skills. To create de-identified databases. We may use your medical information for the 1
2 purpose of removing information that tells anyone who you are, and putting it in a computer program. Your information may be completely de-identified or partially deidentified. This information is often used for research purposes. If your information is partially de-identified, it is called a limited data set. HOW YOUR MEDICAL INFORMATION MAY BE DISCLOSED: In addition to using your medical information, we may disclose all or part of it to certain other people. This includes giving your information to: You. In order to get your medical information, you will need to fill out an authorization form. You may also have to pay for the cost of some or all of the copies. People You Ask Us To Give It To. If you tell us that you want us to give your medical information to someone, we will do so. You will need to fill out an authorization form. You may stop this authorization at any time. We are not allowed to force you to give us permission to give your medical information to anyone. We cannot refuse to treat you because you stop this authorization. Situations that will require your authorization include most uses and disclosures of psychotherapy notes, PHI for marketing purposes, and disclosures that constitute a sale of PHI. Other uses and disclosures not described in this Notice and not required or permitted by law will be made only with your authorization. Payers. We have the right to give your medical information to insurance companies, government programs (such as Medicare and Medicaid) and the people who process their claims as well as to others who are responsible for paying for all or part of the cost of treatment provided to you. For example, we may tell your health insurance company what is wrong with you and what treatment is recommended or has been given. Also, if your treatment is or may be covered by worker s compensation, we may give medical information to the people who handle your worker s compensation, the Louisiana Office of Worker s Compensation Administration and to your employer. Our business associates. Business associates are companies or people that we contract with to do certain work for us. Examples include information to auditors, attorneys and specialized people providing management, analysis, utilization review or other similar services to us. Another example is the giving of health information to a business associate so that the business associate can create a de-identified data base. Business associates are required to agree to take reasonable steps to protect the privacy of your medical information. Limited Data Set Recipients. If we use your information to make a limited data set, we may give the limited data set that includes your information to others for the purposes of research, public health action or health care operations. The persons who receive limited data sets are required to agree to take reasonable steps to protect the privacy of your medical information. The Secretary of the U. S. Department of Health and Human Services. The Secretary has the right to see your records in order to make sure we follow the law. 2
3 Public Health Authorities. We may disclose your medical information to a public health authority responsible for preventing or controlling disease, maintaining vital statistics or other public health functions. We may also give your medical information to the Food and Drug Administration in connection with FDA-regulated products. Law Enforcement Officers. We may reveal your medical information to the police. We may also give your medical information to persons whose job is to receive reports of abuse, neglect or domestic violence. And, if we believe that releasing this information is needed to prevent a serious threat to the health or safety of a person or the public, we are allowed to reveal your medical information. Health Oversight Agencies. We may give your medical information to agencies responsible for health oversight activities, such as investigations and audits, of the health care system or benefit programs, as allowed by law. Courts and Administrative Agencies. We may reveal your medical information as required by a judge for a legal issue. Coroners and Funeral Directors. We may reveal medical information about persons who have died to coroners, medical examiners and funeral directors, as allowed by law. Organ Transplant Services. We may reveal your medical information to agencies that are responsible for getting and transplanting organs. Research. We may reveal your medical information in connection with certain research activities. With your authorization, we may disclose pertinent information such as your name, social security number, study name, and dates of participation to our Accounts Payable department to issue human research subjects reimbursement and/or compensation payments. Specialized Governmental Functions. We may disclose your medical information for certain specialized governmental functions, as allowed by law. Such functions include: Military and veterans activities National security and intelligence activities Protective services to the President and others Medical suitability determinations; and Correctional institutions and other law enforcement custodial situations. Required by Law. We may also reveal your medical information in any other circumstance where the law requires us to do so. OBJECTIONS TO USES AND DISCLOSURES: In certain situations, you have the right to object before your medical information can be used or revealed. This does not apply if you are being treated for certain mental or behavioral problems. If you do not object after you are given the chance to do so, your medical information may be 3
4 used: Patient Directory. In most cases, this means your name, room number and general information about your condition may be given to people who ask for you by name. Also, information about your religion may be given to members of the clergy, even if they do not ask for you by name. Family and Friends. We may disclose to your family members, other relatives and close personal friends, any medical information that they need to know if they are involved in caring for you. For example, we can tell someone who is assisting with your care that you need to take your medication or get a prescription refilled or give them information about how to care for you. We can also use your medical information to find a family member, a personal representative or another person responsible for your care and to notify them where you are, about your condition or of your death. If it is an emergency or you are not able to communicate, we may still give certain information to persons who can help with your care. Disaster Relief. We may reveal your medical information to a public or private disaster relief organization assisting with an emergency. OTHER RIGHTS REGARDING YOUR MEDICAL INFORMATION: You also have the following rights regarding your medical information: You have the right to ask us to treat your medical information in a special way, different from what we normally do. Unless you have the right to object to the use of the information, we do not have to agree with you. If we do agree to your wishes, we have to follow your wishes until we tell you that we will no longer do so. You have the right to tell us how you would like us to send your information to you. For example, you might want us to call you only at work or only at home. Or you may not want us to call you at all. If your request is reasonable, we must follow your request. You have the right to look at your medical information and, if you want, to get a copy of it. We can charge you for a copy, but only a reasonable amount. Your right to look at and copy your medical records is based upon certain rules. For example, we can ask you to make your request in writing or, if you come in person, that you do so at certain times of the day. You have the right to ask us to change your medical information. For example, if you think we made a mistake in writing down what you said about when you began to feel bad, you can tell us. If we do not agree to change your record, we will tell you why, in writing, and give you information about your rights. You have the right to be told to whom we have given your medical information in the six years before you ask. This does not apply to all disclosures. For example, if we gave someone your medical information so that they could treat you or pay for your care, we do not have to keep a record of that. 4
5 You have the right to receive notifications of breaches of your medical information. You have a right to restrict disclosures of your medical information to your payor if you wish to pay out of pocket in full for items or services provided to you. You have the right to opt out of receiving communications regarding fundraising. You have the right to get a copy of this notice at no charge. You have the right to complain to us or to the United States Department of Health and Human Services if you believe that we have violated your privacy rights. To complain to us, please contact our Patient Advocate at or by writing to us at Seaside Healthcare, Patient Advocate, 425 Ashley Ridge Blvd., Suite 340, Shreveport, LA If you choose to file a complaint, you will not be penalized in any way. If you would like further information about your rights or about the uses and disclosures of your medical information, you may contact our Compliance/Privacy Office at or by writing to Seaside Healthcare, Compliance/Privacy Office, 425 Ashley Ridge Blvd., Suite 340, Shreveport, LA This notice is effective as of January 7, 2014 Date of Last Revision: January 7,
6 [ENTITY NAME] Acknowledgement of Receipt of Notice of Privacy Practices I acknowledge that I have received a copy of the Notice of Privacy Practices of this date. Date: Patient s Signature Health Care Provider s Documentation of Good Faith Effort to Obtain Acknowledgement of Receipt If the Acknowledgement could not be obtained prior to the date of first service to the patient, or, in an emergency situation, as soon as reasonably practicable after the emergency has resolved, describe below the efforts made to obtain the written Acknowledgement and the reasons why the written acknowledgement could not be obtained. If the patient refused to provide the written acknowledgement, please so state. Efforts to obtain written Acknowledgement: Reasons written Acknowledgement could not be obtained: (Signature of health care provider) Date (Printed name of health care provider) 6
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