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THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION.
This notice describes our information privacy practices and that
of:
- Any health care professional authorized to enter
information into your medical record created and/or maintained
at our facility;
- Any member of a volunteer group which we allow
to help you while receiving services at our facility; and
- All facility employees, staff, and other authorized
facility personnel.
All of the individuals or entities identified above
will follow the terms of this notice. These individuals or entities
may share your “Protected Health Information” or PHI
with each other for purposes of treatment, payment, or health
care operations, as further described in this notice.
Uses or disclosures of your health information
Our policy regarding your health information
We are legally required and committed to preserving and protecting
the privacy and confidentiality of your PHI created and/or maintained
at our facility. This health information is information that could
be used to identify you and is called “Protected Health
Information” or PHI. Certain state and federal laws
and regulations require us to implement policies and procedures
to safeguard the privacy of your health information.
This notice will provide you with information regarding
our privacy practices and applies to all of your PHI created and/or
maintained at our facility, including any information that we receive
from other health care providers or facilities. The notice describes
the ways in which we may use or disclose your PHI and describes
your rights and our obligations regarding any such uses or disclosures.
We will abide by the terms of this notice, including any future
revisions that we may make to the notice as required or authorized
by law.
We reserve the right to change this notice
and to make the revised or changed notice effective for PHI we already
have about you as well as any information we receive in the future.
The first page of the notice contains the effective date and any
dates of revisions to this document. We will post a copy of the
current notice in our facility.
We may use or disclose your PHI in one of following
ways:
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Pursuant to your written authorization (for purposes
other than treatment, payment or health care operations)
-
Pursuant to your verbal agreement (for use in
our facility directory or to discuss your health condition with
family or friends who are involved in your care)
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As permitted by law
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As required by law
The following describes each of the different ways
that we may use or disclose your health information. Where appropriate,
we have included examples of the different types of uses or disclosures.
While not every use or disclosure is listed, we have included all
of the ways in which we may make such uses or disclosures.
How we may use or disclose your PHI
We may use or disclose your PHI for purposes of treatment,
payment, or health care operations.
Treatment. We may use your PHI to provide
you with health care treatment and services. We may disclose your
PHI to doctors, nurses, nursing assistants, medication aides,
technicians, medical and nursing students, rehabilitation therapy
specialists, or other personnel who are involved in your health
care. For example, your physician may order physical therapy services
to improve your strength and walking abilities. Our nursing staff
will need to talk with the physical therapist so that we can coordinate
services and develop a plan of care. We also may disclose your
PHI to people outside of our facility who may be involved in your
health care, such as family members, social services, or home
health agencies.
Except in emergency situations, we may not disclose
PHI which shows you received mental health treatment services
to anyone outside the office, practice or organizational affiliate
of St. Mary’s without your written authorization. We may
communicate with a pharmacist to permit dispensing of medication
as needed.
Appointment reminders. We may use or disclose
your PHI for purposes of contacting you to remind you of a health
care appointment.
Treatment alternatives, health-related benefits
and services. We may use or disclose your PHI for purposes
of contacting you to inform you of treatment alternatives or health-related
benefits and services that may be of interest to you.
Payment. We may use or disclose your PHI
so that we may bill and collect payment from you, an insurance
company or another third party for the health care services you
receive at our facility. For example, we may need to give information
to your health plan regarding the services you received from our
facility so that your health plan will pay us or reimburse you
for the services. We also may tell your health plan about a treatment
you are going to receive in order to obtain prior approval for
the services or to determine whether your health plan will cover
the treatment.
Health care operations. We may use or disclose
your PHI to perform certain functions within our facility. These
uses or disclosures are necessary to operate our hospital and
to make sure that our patients receive quality care. 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
combine PHI about many of our patients to determine whether certain
services are effective or whether additional services should be
provided. We may disclose your PHI to physicians, nurses, nursing
assistants, medication aides, rehabilitation therapy specialists,
technicians, medical and nursing students and other personnel
for review and learning purposes. We also may combine PHI with
information from other health care providers or facilities to
compare how we are doing and see where we can make improvements
in the care and services offered to our residents. We may remove
information that identifies you from this set of PHI so that others
may use the information to study health care and health care delivery
without learning the specific identities of our residents.
Fundraising activities. We may use a limited
amount of your PHI for purposes of contacting you to raise money
for our facility and its operations. We may disclose this PHI
to a foundation related to the facility so that the foundation
may contact you to raise money for our facility. The information,
which we may use or disclose, will be limited to your name, address,
phone number and dates for which you received treatment or services
at our facility.
If you
do not want our facility or affiliated foundation to contact you
for these fundraising purposes, you must notify Sisters of Charity
Foundation in writing at:
Sisters of Charity Foundation
Box 291
Lewiston, ME 04240
Uses or disclosures made pursuant to your verbal
agreement
We may use or disclose your health information, pursuant
to your verbal agreement, for purposes of including you in our directory
or for purposes of releasing information to persons involved in
your care as described below.
Directory. We may use or disclose certain
limited PHI about you in our facility phone and/or room directories
while you are a patient. This information may include your name,
your assigned unit and room number, your religious affiliation
and a general description of your condition. Your religious affiliation
may be given to a member of the clergy. The directory information,
except for religious affiliation, may be given to people who ask
for you by name.
Individuals involved in your care. We may
disclose your PHI to individuals, such as family and friends,
who are involved in your care or who help pay for your care. We
also may disclose your PHI to a person or organization assisting
in disaster relief efforts for the purpose of notifying your family
or friends involved in your care about your condition, status
and location.
Uses or disclosures permitted by law
Certain state and federal laws and regulations either
require or permit us to make certain uses or disclosures of your
PHI without your permission. These uses or disclosures are generally
made to meet public health reporting obligations or to ensure the
health and safety of the public at large. The uses or disclosures,
which we may make pursuant to these laws and regulations, include
the following:
Public health activities. We may use or disclose
your PHI to public health authorities that are authorized by law
to receive and collect PHI for the purpose of preventing or controlling
disease, injury or disability. We may use or disclose your PHI
for the following purposes:
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To report births and deaths
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To report suspected or actual abuse, neglect,
or domestic violence involving a child or an adult
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To report adverse reactions to medications
or problems with health care products
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To notify individuals of product recalls
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To notify an individual who may have been exposed
to a disease or may be at risk for spreading or contracting
a disease or condition
Health oversight activities. We may use or
disclose your PHI to a health oversight agency that is authorized
by law to conduct health oversight activities. These oversight
activities may include audits, investigations, inspections, or
licensure and certification surveys. These activities are necessary
for the government to monitor the persons or organizations that
provide health care to individuals and to ensure compliance with
applicable state and federal laws and regulations.
Judicial or administrative proceedings. We
may use or disclose your PHI to courts or administrative agencies
charged with the authority to hear and resolve lawsuits or disputes.
We may disclose your PHI pursuant to a court order, a subpoena,
a discovery request, or other lawful process issued by a judge
or other person involved in the dispute, but only if efforts have
been made to (i) notify you of the request for disclosure or (ii)
obtain an order protecting your health information.
Worker’s compensation. We may use or
disclose your PHI to worker’s compensation programs when
your health condition arises out of a work-related illness or
injury.
Law Enforcement official. We may use or disclose
your PHI in response to a request received from a law enforcement
official for the following purposes:
-
In response to a court order, subpoena, warrant,
summons or similar lawful process if disclosure is authorized
or required by statute
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If necessary to protect public health or welfare
if disclosure is authorized or required by law
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Regarding a victim of a crime if, under certain
limited circumstances, we are unable to obtain the person’s
agreement
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To report a death that we believe may be the
result of criminal conduct
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To report criminal conduct at our facility
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In emergency situations, to report a crime—the
location of the crime and possible victims; or the identity,
description, or location of the individual who committed the
crime
Coroners, medical examiners, or funeral directors.
We may use or disclose your PHI to a coroner or medical examiner
for the purpose of identifying a deceased individual or to determine
the cause of death. We also may use or disclose your PHI to a
funeral director for the purpose of carrying out his/her necessary
activities.
Organ procurement organizations or tissue banks.
If you are an organ donor, we may use or disclose your PHI to
organizations that handle organ procurement, transplantation or
tissue banking for the purpose of facilitating organ or tissue
donation or transplantation.
Research. We may use or disclose your PHI
for research purposes under certain limited circumstances. Because
all research projects are subject to a special approval process,
we will not use or disclose your PHI for research purposes until
the particular research project for which your PHI may be used
or disclosed has been approved through this special approval process.
However, we may use or disclose your PHI to individuals preparing
to conduct the research project in order to assist them in identifying
patients with specific health care needs who may qualify to participate
in the research project. Any use or disclosure of your PHI, which
may be done for the purpose of identifying qualified participants,
will be conducted onsite at our facility. In most instances, we
will ask for your specific permission to use or disclose your
PHI if the researcher will have access to your name, address or
other identifying information.
To avert a serious threat to health or safety.
We may use or disclose your PHI when necessary to prevent a serious
threat to the health or safety of you or other individuals. Any
such use or disclosure would be made solely to the individual(s)
or organization(s) that have the ability and/or authority to assist
in preventing the threat.
Military and veterans. If you are a member
of the armed forces, we may use or disclose your PHI to provide
a brief confirmation of general health status as required by military
command authorities.
National security and intelligence activities.
We may use or disclose your PHI to authorized federal officials
for purposes of intelligence, counterintelligence and other national
security activities, as authorized or required by law.
Inmates. If you are an inmate of a correctional
institution or under the custody of a law enforcement official,
we may use or disclose your PHI to the correctional institution
or to the law enforcement official as may be necessary to provide
information about immunizations and/or a brief confirmation of
general health status.
Uses or disclosures required by law
We may use or disclose your information where such
uses or disclosures are required by federal, state or local law.
Uses or disclosures that require your written authorization
We may use or disclose your PHI for purposes other
than treatment, payment or health care operations or as described
in this document and for purposes which are not required by law
only after receiving your written authorization.
Your rights regarding your health information
You have the right to revoke a written authorization
at any time as long as your revocation is provided to us in writing.
If you revoke your written authorization, we will no longer use
or disclose your PHI for the purposes identified in the authorization.
You understand that we are unable to retrieve any disclosures that
we may have made pursuant to your authorization before its revocation.
Some examples of uses or disclosures that may require your written
authorization include a request to provide your PHI to an attorney
for use in a civil litigation claim and/or for purposes of including
you on a mailing list.
You have the following rights regarding your PHI that
we create and/or maintain:
Right to inspect and copy. You have the right
to inspect and copy PHI that may be used to make decisions about
your care. Generally, this includes medical and billing records
but does not include psychotherapy notes.
To inspect and copy your health information, you
must submit your request in writing to:
(Your Provider’s Name here)
PO Box 291
Lewiston, ME 04240
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 your
PHI in certain limited circumstances. If you are denied access
to your health information, you may request that the denial be
reviewed. Another licensed health care professional selected by
our facility will review your request and the denial. The person
conducting the review will not be the person who initially denied
your request. We will comply with the outcome of this review.
Right to request an amendment. If you feel
that 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 the information is kept by or for
our facility.
To request an amendment, your request must be made
in writing and submitted to:
(Your Provider’s Name here)
PO Box 291
Lewiston, ME 04240
We may deny your request for an amendment if it
is not in writing. In addition, we may deny your request if you
ask us to amend information that is not part of the PHI kept by
or for our facility and/or information which you would be permitted
to inspect and copy.
Right to an accounting of disclosures. You
have the right to request an accounting of the disclosures that
we have made of your health information. This accounting will
not include disclosures of PHI that we made for purposes of treatment,
payment or health care operations or for disclosures we made that
you authorized us to make.
To request an accounting of disclosures, you must
submit your request in writing to:
(Your Provider’s Name here)
PO Box 291
Lewiston, ME 04240
Your request must state a time period that may not
be longer than six (6) years before the date of your request and
may not include dates before April 14, 2003. Your request should
indicate in what form you want to receive the accounting (for
example, on paper or via electronic means). The first accounting
that you request within a twelve (12)-month period will be free.
For additional accountings, we may charge you for the costs of
providing the accounting. 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 for treatment, payment, or health care operations.
You also have the right to request a limit on the PHI we disclose
about you to someone, such as a family member or friend, who is
involved in your care or in the payment of your care. For example,
you could ask that we not use or disclose information regarding
a particular treatment that you received.
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 emergency treatment to you.
To request restrictions, you must make your request
in writing to:
(Your Provider’s Name here)
PO Box 291
Lewiston, ME 04240
In your request, 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 a family member).
Right to request confidential communications.
You have the right to request that we communicate with you about
your health care 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:
(Your Provider’s Name here)
PO Box 291
Lewiston, ME 04240
We will not ask you the reason for your request.
We will accommodate all reasonable requests. Your request must
specify how and or where you wish to be contacted.
Right to a paper copy of this notice. You
have the right to receive 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.
You may obtain a copy of this notice at our Web site:
www.stmarysmaine.com
To obtain a paper copy of this notice, contact your
provider or mail a written request to:
(Your Provider’s Name here)
PO Box 291
Lewiston, ME 04240
COMPLAINTS
If you believe your privacy rights have been violated,
you may file a complaint in writing, with Judy Caron, our compliance
manager at St Mary’s Compliance Office, PO Box 291, Lewiston,
ME 04240 or by sending an e-mail at jcaron@sochs.com.
You may also file a complaint with the Secretary of
the Department of Health and Human Services (“HHS”) at
200 Independence Avenue, S.W., Washington, D.C. 20201 or by sending
HHS an e-mail at HHS.Mail@hhs.gov.
All complaints must be submitted in writing.
You will NOT be penalized
for filing a complaint.
Last
reviewed/revised 8/21/07
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