HIPAA Privacy Notice

PRIVACY PRACTICES NOTICE  

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
 

 

PLEASE REVIEW THIS CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

 

 {The following summary section is optional, though suggested by DHHS for a ?layered notice? at 67 Fed. Reg. p. 53243 (Aug. 14, 2002).}

 

Summary of Privacy Practices

We may use and disclose your medical information, without your permission, for treatment, payment, and health care operations activities and, when required or authorized by law, for public health and interest activities, law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions.

We may disclose your medical information to your family members, friends, and others you involve in your health care or payment for health care and to appropriate public and private agencies in disaster relief situations.

 {We may disclose to your employer your medical information, our findings from medical surveillance of your employer's workplace, and evaluation of whether an illness or injury is work-related.}  

We will not otherwise use or disclose your medical information without your written authorization. 

You have the right to examine and receive a copy of your medical information, to receive an accounting of certain disclosures we may make of your medical information, and to request that we amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information. 

Please review this entire notice for details about the uses and disclosures we may make of your medical information, about your rights and how to exercise them, and about complaints regarding or additional information about our privacy practices.

 

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your medical information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect March 1, 2003, and will remain in effect unless we replace it.

 We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable laws. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice, post the revised notice at each of our service delivery sites, and make the new notice available to our patients and others upon request.

 

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information at the end of this notice.
 

 

Uses and Disclosures of Medical Information
 

 

Treatment: We may use and disclose your medical information, without your permission, to treat you. We may disclose your medical information, without your permission, to a physician or other health care provider for your treatment. These treatment activities include coordination, referral, and consultation with health providers and health plans related to your care.

 

Payment: We may use and disclose your medical information, without your permission, to obtain or provide reimbursement for health care we provide to you, including submitting claims to health plans, or other insurers. These payment activities include justifying our charges for and demonstrating the medical necessity of the care we deliver to you, determining your eligibility for health plan benefits for the care we furnish to you, obtaining precertification or preauthorization for your treatment or referral to other health care providers, participating in utilization review of the services we provide to you, and the like. We may disclose your medical information to another health care provider or to a health plan for that provider or plan to obtain payment or engage in other payment activities with respect to your health care.
 

 

Health Care Operation: We may use and disclose your medical information, without your permission, for health care operations. Health care operations include:
 

 

1.      Health care quality assessment and improvement activities;
2.      Reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing and credentialing activities;
3.     Conducting or arranging for medical reviews, audits, and legal services including fraud and abuse detection and prevention; and
4.      Business planning, development, management, and general administration, including customer service, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.
 

We may disclose your medical information to a health plan or another health care provider who is subject to federal privacy protection laws, as long as the provider or plan has or had a relationship with you and the medical information is for that provider's or plan's health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

   
Your Authorization: You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice.
 

 Family, Friends, and Others Involved in Your Care or Payment for Care: We may disclose your medical information to a family member, friend or any other person you involve in your health care. We will disclose only the medical information that is relevant to the person's involvement. We may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your health care in appropriate situations, such as a medical emergency or during disaster relief efforts.

 Before we make such a disclosure, we will provide you with an opportunity to object. If you are not present, are incapacitated, or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances.

 

Facility Directories: Unless you object when we ask you, we may list your name, your general medical condition, your religious affiliation, and your location in our facility in our facility directories. We will disclose your religious affiliation only to clergy. We will disclose the other information only to persons who ask for you by name.

 If you are not present, are incapacitated, or it is an emergency or disaster relief situation, we will use our professional judgment and any prior preference you may have expressed, to determine if listing your information in our facility directories is in your best interest. If we list your information, we will ask whether you object to continuing the listing as soon as you become available.

 

 Individuals may contact William Bee Ririe Hospital's Privacy Officer at the office of Medical Records located in the hospital: 1500 Avenue H, Ely, Nevada 89301. E-mail privacy@wbrhely.org,  or call (775) 289-3467 Extension 231.

 
         
If an individual inquires about the address for filing complaints with the U.S. Department of Health and Human Services, it is:
 

 

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
OCR Hotlines-Voice: 1-800-368-1019
 

 

 Revised: 4-25-03

 

 

 

NOTICE ACKNOWLEDGEMENT
 

 

WILLIAM BEE RIRIE CRITICAL ACCESS HOSPITAL & RURAL HEALTH CLINIC

 

Purpose: This form is used to document an individual's acknowledgement of receipt of our Privacy Practices Notice or our good faith, but unsuccessful effort to obtain that acknowledgement. We are not obligated to attempt to obtain this acknowledgement in an emergency treatment situation.

 SECTION A: Individual receiving Privacy Practices Notice.

Name: _________________________________________________________________________________________

 Address: ________________________________________________________________________________________

 Telephone: _______________________________ E-mail: ________________________

 Account Number: _________________ Birth Date: _________________

 

 

 

TO THE INDIVIDUAL: Please complete the following acknowledgement.

 

I acknowledge that I received the Privacy Practices Notice of William Bee Ririe Hospital & Rural Health Clinic.

 Signature: _________________________ Date: ___________________ Time: _________________

 If this authorization is signed by a personal representative on behalf of the individual, complete the following:

 Personal Representative's Name: __________________________________________________________________

 Relationship to Individual: _______________________________________________________________________

 SECTION B: Good faith effort to obtain acknowledgement (complete only if you fail to get individual's signed acknowledgement on this form or otherwise).

 Individual refused or was unable to sign an acknowledgement that the individual received our Privacy Practices Notice. Described your good faith effort to obtain the individual's signed acknowledgement and the reason you were unsuccessful: Individual received the joint Privacy Practices Notice applicable to our organization from another participant in an organized health care arrangement with us. We are therefore not required to deliver a Notice or obtain an acknowledgement. Attach a copy of the acknowledgement, or the documentation of the good faith, but unsuccessful effort to obtain acknowledgement, from the participant who furnished the joint notice.

  •  
        .    Individual received our privacy Practices Notice in connection to an emergency 
             treatment situation. We are therefore not required to obtain an acknowledgement.

 

 SIGNATURE.    I attest that the above information is correct.

 Signature: __________________________________________   Date:  _______________________

 Print name: __________________________________________ Title: _______________________

 Include completed form in the individual's records.  

 Send copy to the Privacy Official

 Revised: 4-25-03

Copyright © 2012, William Bee Ririe, All rights reserved.