Notice Of Privacy Practices
Effective Date: August 8, 2008
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 NOTICE CAREFULLY.
Guthrie Health refers to Guthrie Health and its affiliated entities such as Robert Packer Hospital, Guthrie Clinic Ltd., Guthrie Medical Group, P.C., Corning Hospital and Troy Community Hospital. Guthrie Health also includes other entities affiliated with Guthrie Health. If you have a question about whether an entity is affiliated with Guthrie Health, please contact us using the information listed at the end of this Notice. This Notice applies to information and records regarding your health care maintained at Guthrie Health. Guthrie Health entities and their employees, staff, students, volunteers and others involved in patient care to which this Notice applies (referred to as “we,” “our,” and “us”) have agreed to abide by its terms. We may share your information with each other for purposes of treatment, and as necessary for payment and operations activities as described below.
In the course of receiving services from Guthrie Health (“Guthrie”), you will provide us with personal information about your health, with the understanding that this information will be kept confidential. We may also obtain information about your health from examinations, tests, or from others who have provided you with care. This notice of our privacy practices is intended to inform you of the ways we may use your information and the occasions on which we may disclose this information to others.
We use patients’ information when providing treatment. We disclose patients’ information to other health care providers to assist them to provide you with treatment. We may disclose information to insurance companies as necessary to receive payment. We may use the information within our organization to evaluate quality and improve health care operations, and we may make other uses and disclosures of patients’ information as required by law or as permitted by Guthrie policies.
OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
Guthrie is committed to protecting medical information about you. We create a record of the care and services you receive at Guthrie for use in your care and treatment.
This Notice tells you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information.
We are required by law to:
- make sure that your medical information is protected;
- give you this Notice describing our legal duties and privacy practices with respect to medical information about you; and
- follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following sections describe different ways that we may use and disclose your medical information. For each category of uses or disclosures, we will describe them and give some examples. Some information such as certain drug and alcohol information, HIV information and mental health information is entitled to special restrictions related to its use and disclosure. Guthrie abides by all applicable state and Federal laws related to the protection of this information. Not every use or disclosure will be listed. All of the ways we are permitted to use and disclose information, however, will fall within one of the following categories.
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, students, or others who are involved in taking care of you in our system. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the hospital's food service if you have diabetes so that we can arrange for appropriate meals. We may also share medical information about you with other Guthrie personnel or non-Guthrie providers, agencies or facilities in order to provide or coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside Guthrie who may be involved in your continuing medical care after you leave Guthrie such as other health care providers, transport companies, community agencies and family members.
We may use and disclose medical information about you so that the treatment and services you receive at Guthrie or from other entities, such as an ambulance company, may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to give information to your health plan about surgery you received at Guthrie so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.
We will use your health information, and disclose it to others, as necessary to obtain payment for the services we provide to you. For instance, an employee in our business office may use your health information to prepare a bill. We may send that bill, and any health information it contains, to your insurance company. We may also disclose some of your health information to companies with whom we contract for payment-related services. For instance, we may give information about you to a collection company that we contract with to collect bills for us. We will not use or disclose more information for payment purposes than is necessary.
Health Care Operations
We may use and disclose medical information about you for Guthrie operations. These uses and disclosures include but are not limited to quality of care and medical staff activities, health sciences education within Guthrie, and teaching programs with affiliates and within other health care arrangements. Your medical information may also be used or disclosed to comply with law and regulation, to assess your satisfaction with our services, for population based activities relating to improving health or reducing health care costs, for contractual obligations, patients' claims, grievances or lawsuits, health care contracting, legal services, business planning and development, business management and administration, underwriting and other insurance activities and to operate the Guthrie enterprise system. For example, we may review medical information to find ways to improve treatment and services to our patients. We may also disclose information to doctors, nurses, technicians, medical and other students, and other Guthrie personnel for performance improvement and educational purposes.
Public Health Risks
We will disclose your health information when required to do so for public health purposes. These purposes generally include the following:
- reporting certain disease (such as cancer and tuberculosis), injury or disability;
- reporting vital events such as births and deaths;
- reporting child abuse or neglect;
- reporting adverse events or reactions to certain medications or defects or problems with products;
- notifying persons of recalls, repairs or replacements of products they may be using;
- notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.
To Report Abuse
We may disclose your health information when the information relates to a victim of abuse, neglect or domestic violence. We will make this report only in accordance with laws that require or allow such reporting, or with your permission.
We may disclose your health information for law enforcement purposes:
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
- About a death suspected to be the result of criminal conduct;
- About criminal conduct at Guthrie;
- In case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime; and to a Federal agency investigating our compliance with Federal privacy regulations.
We may contact you to remind you that you have an appointment at Guthrie.
We may communicate to you via newsletters, mailings or other means to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may contact you to tell you about benefits or services that we provide that may be of interest to you.
We may contact you to provide information about Guthrie sponsored activities, including fundraising programs and events. We would only use contact information, such as your name, address and phone number and the dates you received treatment or services at Guthrie.
News Gathering Activities
We may contact you or one of your family members when a news reporter has requested an interview with you. News reporters often seek interviews with patients injured in accidents or experiencing particular medical conditions or procedures. For example, a reporter working on a story about a new cancer therapy may ask whether any of the patients undergoing that therapy might be willing to be interviewed. In such cases, a member of our staff would contact you to discuss whether or not you want to participate in the story.
We may list you in our directory if you are admitted to one of our facilities. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy even if they don't ask for you by name. If you request, we will not list you in the directory. You can make your request to the admission staff at the appropriate entity.
Your Family and Friends
: We may disclose to a family member, a friend, or other persons you indicate are involved in your care or payment for your care, your medical information that is directly relevant to their involvement. We may use or disclose your name, location and general condition or death to notify, or help with notification, of a family member, your personal representative, or other persons involved in your care about your situation. If you are present, we will give you the opportunity to object before we disclose your medical information to these persons. If you are incapacitated or in an emergency, we may disclose your medical information to these persons if we determine that the disclosure is in your best interest.
Disaster Relief Efforts
We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Guthrie is a research institution. All research projects conducted by Guthrie are approved through a special review process to protect patient safety, welfare and confidentiality. Your medical information may be important to further research efforts and the development of new knowledge. We may use and disclose medical information about our patients for research purposes, subject to the confidentiality provisions of state and Federal law.
On occasion, researchers contact patients regarding their interest in participating in certain research studies. Enrollment in those studies can only occur after you have been informed about the study, had an opportunity to ask questions, and indicated your willingness to participate by signing a consent form. Other studies may be performed using your medical information without requiring your consent. These studies will not affect your treatment or welfare, and your medical information will continue to be protected. For example, a research study may involve a chart review to compare the outcomes of patients who received different types of treatment.
Required by Law:
We may use or disclose your medical information when we are required to do so by law. For example, we must disclose your medical information to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with Federal privacy laws. We may also use and disclose your medical information for the following types of entities, including but not limited to:
- Public Health or Legal Authorities charged with preventing or controlling disease, injury, or disability
- Organ and Tissue Donation Organizations
- Military Command Authorities
- Workers’ Compensation Agents
- Health Oversight Agencies
- Coroners, Medical Examiners and Funeral Directors
- Protected Services for the President and Others
- National Security and Intelligence Agencies
- Correctional Institutions
- Food and Drug Administration
Lawsuits and Other Legal Actions
In connection with lawsuits or other legal proceedings, we may disclose medical information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons or other lawful process.
We may disclose your health information for a number of other specialized purposes. We will only disclose as much information as is necessary for the purpose. For instance, we may disclose your information to your employer for purposes of compliance with work site safety laws (Federal Occupational Safety and Health Act (OSHA) for instance) or similar programs.
We provide some services through contracts with business associates, for example, a copy service we use when making copies of your health record. When these services and other services with business associates are contracted, we may disclose your health information to our business associates so they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Health Benefits Information
Your health information may be disclosed by the Guthrie Network Advantage Health Plan to Guthrie Health employees, as necessary for the administration of the health benefit program. Employees who receive this information have special rules to prevent the misuse of your information for other purposes.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Your medical information is the property of Guthrie; however, you have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy
With certain exceptions, you have the right to inspect and/or receive a copy of your medical information. To inspect and/or to receive a copy of your medical information, you must submit your request in writing to the Medical Record Custodian at the appropriate Guthrie entity. If you request a copy of the information, we may charge a fee for copying and mailing the records.
We may deny your request to inspect and/or to receive a copy of certain information in certain limited circumstances. If we do, we will give you the reason in writing. In some cases you may have the denial reviewed. We will also explain how you may appeal the decision.
Right to Request an Amendment
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing and submitted to the Guthrie Health Privacy Office using the contact information listed at the end 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:
- Was not created by Guthrie;
- Is not part of the medical information we use to make decisions about you;
- Is not part of the information which you would be permitted to inspect and copy;
- Is accurate and complete in the record.
Right to an Accounting of Disclosures
You have the right to receive a list of the disclosures we have made of medical information about you that were for purposes other than treatment, payment, health care operations and certain other purposes.
To request this accounting of disclosures, you must submit your request in writing to the Guthrie Health Privacy Office. Please refer to the Privacy Office contact information at the end of this Notice. Your request must state a time period that may not be longer than the six previous years and may not include dates before April 14, 2003. You are entitled to one accounting within any 12-month period at no cost. If you request a second accounting within that 12-month period, there will be a charge for the cost of compiling 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 ask us to restrict how we use or disclose your health information. We will consider your request, but we are not required to agree. If we do agree, our agreement must be in writing and we will comply with the request unless the information is needed to provide you with emergency treatment. We cannot agree to restrict disclosures that are required by law.
To request a restriction, you must make your request in writing to the Guthrie Health Privacy Office using the contact information listed at the end of this Notice. In your request, you must tell us what information you want to limit.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you at work instead of your home. We will grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by us and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
Right to a Paper Copy of This Notice
You have the right to 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.
Copies of this Notice shall be available throughout Guthrie, or you may obtain a copy at our website, www.guthrie.org.
OTHER USES OF MEDICAL INFORMATION
We may use or disclose your health information for any purpose that is covered by this Notice without your written authorization. Other uses and disclosures of medical information not covered by this Notice will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we will retain our records of the care provided to you as required by law. If the authorization is to permit disclosure of your information to an insurance company, as a condition of obtaining coverage, other law may allow the insurer to continue to use your information to contest claims or your coverage, even after you have revoked the authorization.
To revoke a written authorization, send a written statement to the Guthrie Health Privacy Office using the contact information listed at the end of this Notice. The statement must include the date on which the authorization is no longer in force.
CHANGES TO GUTHRIE’S' PRIVACY PRACTICES AND THIS NOTICE
We reserve the right to change our privacy practices and this Notice at any time. We reserve the right to apply these changes to any medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at Guthrie facilities. The Notice will contain the effective date on the first page in the top right-hand corner. In addition, at any time you may request a copy of the current Notice in effect.
QUESTIONS OR COMPLAINTS
If you have any questions about this Notice, please contact us using the information listed at the end of this Notice.
If you believe your privacy rights have been violated, you may file a complaint with Guthrie or with the Secretary of the Department of Health and Human Services. To file a complaint with Guthrie, the contact information is listed below. All complaints must be submitted in writing. We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
One Guthrie Square
Sayre, Pennsylvania 18840
Effective Date: August 8, 2008
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT OF RECEIPT
By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Guthrie Health. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.
Our Notice of Privacy Practicesis subject to change. If we change our Notice, you may obtain a copy of the revised Notice by: (accessing our website at www.guthrie.org / contacting our organization at 1-866-265-9974).
If you have any questions about our Notice of Privacy Practices, please contact:
One Guthrie Square
Sayre, PA 18840
I acknowledge receipt of the Notice of Privacy Practicesof Guthrie Health.
Patient’s Name: Medical Record Number:
(please print legibly)
FOR STAFF USE ONLY IF NO SIGNATURE OBTAINED.
INABILITY TO OBTAIN ACKNOWLEDGEMENT
To be completed only if no signature is obtained. If it is not possible to obtain the individual’s acknowledgement, describe the good faith efforts made to obtain the individual’s acknowledgement, and the reasons why the acknowledgement was not obtained:
(Guthrie Health representative)