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As Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 [HIPAA], This notice describes how health information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
If you have questions about this notice, please contact the HIPAA Privacy Officer. The address and phone numbers are listed on the back of this Notice. Effective Date April 14, 2003
Our Pledge Regarding Your Medical Information Your Protected Health Information [PHI] includes information about your physical and mental health, your care and payment for care. We know that information about you and your health is personal. We will make every reasonable effort to protect information about you. Each time you receive care or service at our facility, we create a record of that care. We need this record to take care of you, to be paid for giving you care and to comply with business and legal requirements. This notice applies to all of the records containing your PHI made by and kept by our facilities. This notice will tell you about the way in which we may use and disclose medical information about you. It also tells you about your rights and certain obligations we have regarding the use and disclosure of your PHI. We are required by HIPAA Regulations to:
Who will follow this Privacy Notice
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give an example. 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 into one of the categories. For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at the hospital. For example, test results will be given to your doctor in order to plan and provide your care. Different departments of the hospital also may share medical information about you in order to coordinate the care you need, such as prescriptions, lab work and x-rays. If you are transferred to another facility, we will send copies of relevant PHI to ensure your care is continued. For Payment. We may use and disclose health information about you so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Health Care Operations. We may use and disclose medical information about you to operate our business. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. Examples of this type of use include evaluation of care, evaluation of employee performance, accreditation activities, and general management of the facility. Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you such as newer, upgraded medical equipment. Health-Related Benefits and Services. We may use and disclose medical information to tell you about health related benefits or services that may be of interest to you such as a health screening. Directory. We may include certain limited information about you in a directory while you are a patient in the facility. This information may include your name, location in the facility, and your religious affiliation. Unless you tell us that you object, this information will be given to members of the clergy and, except for religion, to other people who ask for you by name. Appointment Reminders. We may use your PHI to contact you to remind you of an appointment or to collect information from you before you use our facility or services. Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your care. We may also give information to someone who helps pay for your care. In an emergency, we may disclose medical information about you so that your family can be notified about your condition, status and location. Required disclosures of PHI We are required by various laws and regulations to report health information to persons or agencies. These disclosures do not require your permission. As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you 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 the threat. Organ and Tissue Donation. If you are an organ donor, we may release medical information to 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 release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. Worker's Compensation. We may release your PHI for worker's compensation and similar programs, as required by applicable law. Public Health Risks. We may disclose your PHI to public health or government agencies that are required to collect information such as, but not limited to, the following:
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you 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. Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials to protect the President or other heads of state and for intelligence, counterintelligence, and other national security activities authorized by law. Inmates. PHI may be given to correctional officers for persons in custody. This is necessary to ensure your care is continued, for the safety and security of the institution and/or to protect your health and safety or that of other individuals. Your Rights regarding PHI . . . While the medical record itself belongs to the facility, you have rights regarding medical information we maintain about you: Right to Inspect and Copy. You have the right read and copy medical information used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. Information restricted by law or some other legal process may not be available to you. You must submit your request in writing to Health Information Department [Medical Records] at the address on the back of this notice. If you request a copy of the information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request. Please contact the Director of Medical Records for information about fees. We may deny your request to read and copy some or all of your PHI in certain very limited circumstances. If this happens, you may ask that the denial be reviewed. Another licensed health care professional chosen by the facility 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 a Paper Copy of This Notice. You have the right to a paper copy of this Privacy Notice. You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this notice contact the HIPAA Privacy Officer at the address or phone number on the back of this notice. Right to Amend. If you feel that PHI we have about you is wrong or not complete, 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 the hospital. To request an amendment, your request must made in writing and submitted to HIPAA Privacy Officer at the address on the back of this Notice. 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:
You have the right to ask 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. We will accommodate reasonable request but we are not required to accommodate all requests. To request confidential communications, you must make your request in writing to the Admissions Department when you register or to the Privacy Officer at the address on the back of this Notice. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you for reasons other than treatment, payment, or health care operations or that you have given written permission for. It also will not include disclosures to you, directory information disclosure, incidental disclosures in the course of your care, national security or law issues, and disclosures where most of the identifiable information about you has been removed as allowed by HIPAA. To request this list or accounting of disclosures, you must put your request in writing to the Director of Medical Records at the facility where you received care. [Addresses are on the back of this notice] A Request form is available. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. 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 you are charged. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request we limit medical information we disclose about you to someone who is involved In your care or the payment for your care, like a family member or friend. 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 you emergency treatment or is required by law. To request restrictions, you must make your request in writing to the Privacy Officer at the address on the back of this Notice. In your request, you must tell us (1) what information you want to limit and how; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. Other Uses of Medical Information Other uses and disclosures of medical information not covered by this notice or laws that apply to us will be made only with your written authorization. If you give us permission to use or disclose medical information about you, you may cancel it, in writing, at any time. If you cancel your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission. We are required to keep our records of the care we provided to you. Complaints If you believe your privacy rights have not been met, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. To file a complaint or request one of your privacy rights, contact the Privacy Officer at the address or phone number on the back of this notice. All complaints should be submitted in writing. Changes to this Notice We reserve the right to revise or change this Privacy Notice. The revised notice will be effective for all of your records, including past and future documents. We will post a copy of the current Privacy Notice in a visible location in each facility. Our Privacy Notice will contain, on the first page, the effective date. In addition, each time you register at or are admitted to a facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect. You may request a copy of the Notice at any time. Ty Cobb Healthcare System Notice of Privacy Practices for Protected Health Information
If you have questions, need more information about your rights and how to use them or want to make a complaint, please contact: HIPAA Privacy Officer Ty Cobb Healthcare System 461 Cook Street Royston, GA 30662 706-245-1825 Ty Cobb Healthcare Facilities and Services
TY COBB HEALTHCARE SYSTEM
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