HIPAA Notice of Privacy Practices
NOTICE OF BETHESDA’S PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION OF SUPPORTED PERSONS
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.
I. Maintaining Privacy. Bethesda Lutheran Communities, Inc. (“Bethesda”) must maintain the privacy of its supported persons’ personal health information and give supported persons notice describing our legal duties and privacy practices concerning supported person personal health information. In general, when we release your health information, we must release only the information we need to achieve the purpose of the use or disclosure. However, all of your personal health information will be available for release to you, to a provider regarding your treatment, or due to a legal requirement. We must follow the privacy practices described in this Notice.
II. Use of Health Information for Treatment, Payment and Health Care Operations. Bethesda is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information (“PHI”) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, conditions, therapies, examination and test results, diagnoses, treatment and applying for future care or treatment. It also includes billing documents for those services.
III. Examples of Use of PHI for Treatment:
A. A nurse obtains treatment information about you and records it in a health record.
B. A staff person uses your health record to determine what medication you need, and records its administration in your health record.
C. A physician records information relevant to your disability in your health record. Bethesda staff use the information in providing services and supports to you.
IV. Examples of Use of PHI for Payment:
A. We submit requests for payment to a government funding agency that provides funding for your services. The agency requires information about your condition, including medical information. We will provide the agency with the required information.
B. We submit requests for payment to your health insurance company. The health insurance company requests information from us regarding your medical care given. We will provide information to them about you and the care given.
V. Examples of Use of PHI for Health Care Operations:
A. Bethesda seeks accreditation from an outside agency. In that process, the accrediting agency reviews supported person health records.
B. A Bethesda manager reviews supported person health records in the course of evaluating an employee’s job performance.
C. A Bethesda administrator reviews supported person health records in the course of evaluating whether changes are needed to an internal policy.
D. Bethesda training staff use supported person health records to train staff on management of a particular medical condition.
VI. We will share your protected health information with third party “business associates” that perform various activities (for example, auditors and attorneys) for Bethesda. Whenever an arrangement between Bethesda and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
VII. We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you. We may contact you as part of a fund raising effort.
VIII. Your Health Information Rights. You have the following rights:
A. Request Restrictions on Certain Uses & Disclosures. You have the right ask for restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities. Or, you may want to limit the health information provided to family or friends involved in your care or payment of medical bills. You may also want to limit the health information provided to authorities involved with disaster relief efforts. However, we are not required to agree in all circumstances to your requested restriction.
B. Notice of Privacy Practices. You are entitled to receive a copy of the current version of this Notice of Bethesda’s Privacy Practices for Protected Health Information (“Notice”) by calling and requesting a copy of our Notice, by visiting our office and picking up a copy, or by viewing the Notice on Bethesda’s public website at www.bethesdalutherancommunities.org. You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this notice electronically.
C. Inspect and Copy Your Health Record. You may exercise this right by making a request in writing to our office, and Bethesda will provide you with a written form for this purpose upon request. We may charge a reasonable fee if you want a copy of your health information. However, this right does not apply to certain records, such as psychotherapy notes or information gathered for legal proceedings. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.
D. Amend or Correct Your Health Record. You may request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request. You may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
E. Get a Record of Disclosures of Your Health Information. You may receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
F. Confidential Communications. You have the right to request to receive confidential communications from us by alternative means or at an alternative location, and Bethesda will provide you with a written form for this purpose upon request. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Official.
IX. Bethesda’s Duties. Bethesda is required to:
A. Maintain the privacy of your health information as required by law.
B. Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you.
C. Abide by the terms of this Notice.
D. Notify you if we cannot accommodate a requested restriction or request.
E. Accommodate your reasonable requests regarding methods to communicate health information with you.
F. Accommodate your request for an accounting of disclosures.
Bethesda reserves the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. If Bethesda amends this Notice in a way that materially changes your rights, Bethesda’s duties, or the privacy practices described in this Notice, we will give you a copy of the revised Notice. You may request a copy of the current form of Notice at any time following the procedures of VIII., B., or may view the current form of Notice on Bethesda’s public website at www.bethesdalutherancommunities.org.
X. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization. Uses and disclosures of your protected health information not otherwise permitted as described in this Notice will be made only with your written authorization made on a form Bethesda will provide you upon request. You may revoke your authorization, at any time, in writing, except to the extent that Bethesda has taken an action in reliance on the use or disclosure indicated in the authorization.
XI. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object. Bethesda may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then Bethesda may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
A. Facility Directories: Unless you object, we may use and disclose in a facility directory your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation.
B. Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
XII. Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, Bethesda shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If Bethesda is required by law to treat you and has attempted to obtain your consent but is unable to do so, Bethesda may still use or disclose your protected health information to treat you.
XIII. Communication Barriers: Bethesda may use and disclose your protected health information if it attempts to obtain consent from you but is unable to do so due to substantial communication barriers and Bethesda determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
XIV. Appointment Reminders and Treatment Alternatives. Bethesda may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits or services that may be of interest to you.
XV. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, No Authorization or Opportunity to Object. We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:
A. Where Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
B. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
C. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
D. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
E. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
F. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
G. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
H. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
I. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
J. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
K. Criminal Activity/Health or Safety: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
L. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
M. Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.
N. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and Bethesda created or received your protected health information in the course of providing care to you.
O. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of 45 C.F.R Section 164.500 et seq.
XVI. Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Official of your complaint. We will not retaliate against you for filing a complaint.
XVII. Bethesda’s Privacy Official. You may contact our Privacy Official to exercise your rights, with questions, or for information about the complaint process.
XVIII. Effective Date. The rights set forth in this Notice became effective on April 14, 2003.