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April 2005 Notice of Privacy Practices NOTE: PHYSICIANS TREATING YOU MAY NOT BE EMPLOYEES OF SHARON REGIONAL HEALTH SYSTEM. SEE EXHIBIT A (PAGE 7) FOR A LISTING OF OUR EMPLOYED PHYSICIANS. SHARON REGIONAL HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective Date: April 14, 2003. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT THE PRIVACY OFFICER. 1. Purpose of this Notice. In general, any information that concerns your health, health care or payment for that care, is considered confidential and protected by Sharon Regional Health System. This Notice describes Sharon Regional Health System's privacy practices, specifically how we use and disclose your medical information and what rights you have with respect to this information. This information may include your name, address, and other identifying data, or information on your health or the health services that have been or may be furnished to you. Sharon Regional Health System requires that all of its affiliates, employees, staff, volunteers and independent contractors comply with these privacy practices with respect to medical information that is used or disclosed by Sharon Regional Health System. 2. Use and Disclosure of Medical Information for Treatment, Payment and Health Care Operations. By law Sharon Regional Health System is allowed to use and disclose your medical information for most treatment, payment and health care operations purposes. Treatment means the provision, coordination or management of health care and related services by or involving Sharon Regional Health System, such as the coordination of consultations and referrals. Sharon Regional Health System can share most medical information regarding your health condition with another provider as part of a consultation. Additionally, Sharon Regional Health System may contact you to make or to confirm that you already made an appointment; to notify you regarding treatment alternatives or other health-related benefits and services that may be of interest to you or to raise funds for Sharon Regional Health System. Please note that by law certain medical information, such as psychotherapy notes, normally may not be used or shared even when it is related to your treatment. Instead, we need to obtain an Authorization (a stricter form of permission) to specifically use or release that information. Payment primarily means Sharon Regional Health System's activities related to getting reimbursed for services it has provided to you. However, payment can also cover activities to determine your eligibility for services with your insurer, coordination of benefits with other insurers, billing, claims management, collection, medical necessity review activities, utilization review activities, and disclosure to consumer reporting agencies. For instance, we can disclose to your health plan medical information that is required by the plan to determine whether the services we have provided to you are medically necessary. Health Care Operations cover a range of activities that are necessary to Sharon Regional Health System's operations. These activities may be performed by Sharon Regional Health System, or in some cases, by third party contractors. These include quality assessment and improvement activities, peer review, credentialing and licensing, training programs, legal and financial services, business planning and development, management activities related to Sharon Regional Health System's privacy practices, customer services, internal grievances, creating de-identified information for data aggregation or other purposes, fund raising, certain marketing activities, and due diligence activities. Examples of Sharon Regional Health System's operations include engaging legal counsel to defend it in any legal actions, evaluation of practitioner performance to insure that they meet quality standards, and fund raising activities, in which Sharon Regional Health System may contact you in order to raise funds for its facilities. 3. Two Uses and Disclosures Require You to Have the Opportunity to Object. (a) For Sharon Regional's Health System's Facility Directory. After we have given you the opportunity to refuse, or in an emergency when we believe that you would want such information to be shared, we can include in our facility directory your name, location in our facility, general health condition and religious affiliation. We may also share relevant information with clergy or a member of the public who inquires about you. (b) To a relative, friend or individual involved in your care, or for disaster relief. Sharon Regional Health System may provide medical information about you to your relatives or friends, or other individuals involved in your care. We will attempt to seek your permission to make this disclosure. If we are not able, for instance, because of your condition or because you are not immediately present, we will use our best judgment to determine whether you would want this information shared. 4. The Following Categories Describe the Different Ways in Which We May Use and Disclose Your Medical Information Without Authorization or Other Written Permission From You: (a) As required by law. Numerous state, federal and local laws permit or require certain uses and disclosures of medical information. However, Sharon Regional Health System may only use or disclose your medical information to the extent authorized by the law. (b) To a public health authority. Sharon Regional Health System may be asked or required by law to divulge medical information to a public health authority under the following circumstances: (i) To report a birth, death, disease or injury, as required by law; (ii) As part of a public health investigation; (iii) To report child or adult abuse or neglect, or domestic violence, as authorized by the law; (iv) To report adverse events (such as product defects), to track products or assist in product recalls or repairs or replacements, or to conduct post-marketing surveillance, as required by the Food and Drug Administration; (v) To notify a person about exposure to a possible communicable disease, as required by law. (c) For health oversight activities. Health oversight activities include audits, government investigations, inspections, disciplinary proceedings, and other administrative and judicial actions undertaken by the government (or their contractors) by way to oversee the health care system. Sharon Regional Health System may be asked or required to share medical information with a health oversight agency for these activities. (d) For judicial and administrative proceedings. Sharon Regional Health System may disclose medical information as required by a court or administrative order, or in some instances pursuant to a subpoena, discovery request or other legal process. (e) To law enforcement. Police and other law enforcement agencies may seek medical information from Sharon Regional Health System. We may release this information to law enforcement officials under limited circumstances, such as when the request is accompanied by a warrant, or when law enforcement needs specific information to locate a suspect to stop a crime from occurring. (f) To coroners, medical examiners and funeral directors. Sharon Regional Health System may release information regarding a decedent as required by law or in order to facilitate burial activities. (g) For organ, eye and tissue donation. Sharon Regional Health System may provide medical information to organ procurement organizations and similar entities in order to facilitate organ, eye and tissue donation. (h) For workers' compensation. Sharon Regional Health System may share information regarding work-related illnesses and injuries in order to comply with applicable workers' compensation laws. (i) If Sharon Regional Health System is required by law to treat you. (j) If the patient is an inmate, in an emergency. (k) To avert a serious threat to health or safety. (l) Medical Information may be disclosed for military, national security, intelligence or correctional activities. (m) For Research Purposes. All research projects are subject to a special approval process which evaluates the proposed research project and its results and balances them against patients' need for privacy of their medical information. 5. Authorizations for Other Uses and Disclosures of Your Medical Information. An Authorization is a written permission that specifically identifies the information that we seek to use or disclose, and when and how we seek to use or disclose it. For example, if you are applying for a life insurance policy, Sharon Regional Health System must obtain your Authorization to share your medical information with that life insurance company. You may revoke an Authorization at any time except to the extent that we have already used or disclosed information in reliance on your Authorization, or your Authorization was obtained as a condition of obtaining insurance coverage. 6. Individual Rights. You have a number of rights with respect to your medical information. They are as follows: (a) Restrictions. You have the right to make a written request to restrict how Sharon Regional Health System uses and discloses your medical information for treatment, payment or operations purposes, or to family, friends, and other individuals involved in your health care. We are bound by an agreement to restrict the use or disclosure of your information except in emergency circumstances. However, we do not have to agree to a restriction if we do not believe that we can or should comply with it. Also, we can ask you to revoke a restriction. Please direct any request for a restriction to The Privacy Officer. (b) Confidential Communications. You have the right to request that Sharon Regional Health System restrict the way in which we communicate information regarding your health, health care services, or payment. For instance, you may ask that we communicate with you only at your home, not at your work. Assuming that we receive your request in writing, we will do our best to reasonably accommodate it. Please discuss with The Privacy Officer how to obtain and complete a written request for confidential communications. (c) Access. You have the right to inspect and copy most of your own medical information maintained by Sharon Regional Health System. Normally, we will provide you with access within 30 days of your request. We may charge you a reasonable copying fee. In certain limited instances, we may deny you access (such as when the information constitutes psychotherapy notes) and you may appeal the denial. Any request to inspect and copy medical information should be made to The Privacy Officer. (d) Amendment. You have the right to ask Sharon Regional Health System to amend written medical information. For example, you can request that we correct an incorrect surgery date in your records. We will generally amend your information within 60 days of your request, and will notify you when we have amended your information. We can deny your request only in certain circumstances, such as when we believe that the information is accurate and complete. If we deny your request, we must inform you of why in writing. You can appeal our denial. Please direct any request to amend your medical information to our Medical Records Department. (e) Accounting. You have the right to request an accounting from Sharon Regional Health System of certain disclosures made by us during the 6 years prior to your request. We will generally provide you with your accounting within 60 days of your request. These disclosures do not include those made for certain purposes including treatment, payment or operations, or for the facility directory. Please forward any requests for an accounting to our Medical Records Department. (f) Paper Notice. If you have obtained this Notice electronically, you may obtain a paper copy by asking The Privacy Officer or any staff member. (g) Complaints. You may complain to Sharon Regional Health System and/or to the Office of Civil Rights (OCR) of the federal Department of Health and Human Services if you believe any right with respect to your medical information has been violated by Sharon Regional Health System, its employees or its agents. If you wish to file a complaint, please contact The Privacy Officer, at 724-983-3821, who will provide you with the appropriate complaint form. You must file a written complaint with the OCR within 180 days of the act or omission that is the basis of the complaint. Under no circumstances will Sharon Regional Health System take any retaliation against you for filing a complaint. (h) Provide an Authorization for Other Uses and Disclosures. Sharon Regional Health System will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to Sharon Regional Health System regarding the use and disclosure of your medical information may be revoked by you at any time in writing. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. 7. Sharon Regional Health System's duties. Sharon Regional Health System is required by law to maintain the privacy of your medical information and to provide you with this Notice of our legal duties and privacy practices with respect to your medical information. We must comply with the Notice currently in effect. We will revise the Notice if we materially change any use, disclosure, individual right or legal duty or other privacy practice stated in this Notice. If we revise a Notice, copies will be made available by asking The Privacy Officer or any Sharon Regional Health System staff member. We will post a copy of our current notice in our offices in a prominent location. We may choose to apply a change in a privacy practice to information that we created or received prior to issuing a revised Notice. In the event Sharon Regional Health System is sold or merged with another organization, your health information will become the property of the new owner. ACKNOWLEDGMENT This is to certify that I, the undersigned hereby consent to and authorize the disclosure of any medical information to the following: +--+ +--+ +--+ +--+ +--+ Husband +--+ Wife +--+ Child +--+ Parent +--+ +--+ Other: Please Specify: May we leave a message at the contact number you provided? +--+ +--+ +--+ Yes +--+ No May you be called at your place of employment to be +--+ +--+ informed of your medical information? +--+ Yes +--+ No If you do not want a certain disclosure made to the above, it is your responsibility to notify us. Thank you for your cooperation. I hereby acknowledge receipt of the Notice of Privacy Practices. Witness: Patient: ______________________________________ Patient Signature Print Name Date: Date: |  |
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