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
Effective Date: April 14, 2003
Revised Date: September 17,2013
St. Peter's Hopsital and all of its affiliated entities (collectively referred to as "we" or "SPH") are committed to protecting the privacy of confidential health care information about you that identifies you, and we are required by laaw to do so. Confidential health care information may be information about health care we provide to you or payment for health care provided to you. It may also be information about your past, present, or future medical condition(s). In this Notice of Privacy Practices (Notice), we will refer to your confidential health care information as "protected health information" or "PHI".
We are also required by law to provide you with this Notice explaininng our legal duties and privacy practices with respect to PHI. We are legally required to follow the terms of this Notice. In other words, we are only allowed to use and disclose PHI in the manner that we have described in this Notice.
We may change the terms os this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all PHI that we maintain. If we make changes to the Notice, we will:
- Post the new Notice in our waiting areas.
- Have copies of the new Notice available upon request. Please contact our front office staff or the Privacy Officer at 406-444-2175 to obtain a copy of our current Notice.
The rest of this notice will:
- Discuss how we may use and disclose PHI about you
- Explain your rights with respect to PHI about you.
- Describe how and where you may file a privacy-related complaint.
If, at any time, you have questions about information in this Notice of about our privacy policies, procedures or practices, you can contact our Privacy Officer at 406-447-2566
We may use and disclose medical information about you in several circumstances.
We use and disclose PHI about patients every day. This section of our Notice explains in some detail how we may use and disclose PHI about you in order to provide health care, obtain payment for that health care, and operate our business effeciently. This section then briefly mentions several other circumstances in which we may use or disclose PHI about you. For more information about any of these uses or disclosures, or about any of our privacy policies, procedures or practices, contact our Privacy Officer at 406-447-2566.
We may use and disclose PHI about you to provide health care treatment to you. In other words, we may use and disclose PHI about you to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others.
Example: Jane is a patient at SPH. The receptionist may us PHI about Jane when setting up and appointment. The nurse practitioner will likely us PHI about Jane when reviewing Jane's condition and ordering a blood test. The Laboratory technician will likely us PHI about Jane when processing or reviewing her blood test results. If, after reviewing the results of the blood test, the provider concludes that Jane shoud be referred to a specialist, the provider may disclose PHI about Jane to the specialist to assist the specialist in providing appropriate care to Jane.
Example: SPH participates in HealthShare Montana's health information exchange and may make your PHI available electronically to other health care providers and plans that are involved in your care and have a legitimate reason to access your information.
We may use and disclose PHI about you to obtain payment for health care services that you received. This means that, within SPH, we may use PHI about you to arrange for payment (such as preparing bills and managing accounts). We also may disclose PHI about you to others (such as insureres, collection agencies, and consumer reporting agencies). In some instances, we may disclose PHI about you to an insurance plan before you receive certain health care services because, for example, we may need to know whether the insurance plan will pay for a particular service.
Example: Jane is a patient at SPH and she has private insurance. During an appointment with a provider, the provider ordered a blood test. The SPH billing clerk will use PHI about Jane when preparing a bill for the services provided at the appoinment and the blood test. PHI about Jane will be disclosed to the isurance company when the billing clerk sends the bill.
Example: The provider referred Jane to a specialist. The specialist recommended several complicated and expensive tests. The specialist's billing clerk may contact Jane's insurance company before the specialist runs the tests to determine whether the plan will pay for the test.
3. Health Care Operations
We may use and disclose PHI about you in performing a variety of business activities that we call "heath care operations." These "health care operations" activities allow us to, for example, improve the quality of care we provide and reduce health care costs. For example, we may use of disclose PHI about you in performing the following activities:
- Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.
- Providing training programs for students, trainees, health care providers or non-health care professionals to help them practice of improve their skills.
- Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty.
- Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients.
- Improving health care and lowering costs for groups of people who have similar heath problems and helping manage and coordinate the care for these groups of people.
- Coopeerating with outside organizations that assess the quality of the care others and we provide, including government agencies and private organizations.
- Planning for our organization's future operations.
- Resolving grievances within our organization
- Reviewing our activities and using or disclosing PHI in the event that control of our organization significantly changes.
- Working with others (such as lawyers, accountants and other providers) who assist us to comply with this Notice and other applicable laws.
Example: Jane was diagnosed with diabetes. SPH used Jane's PHI - as well as PHI from other SPH patients diagnosed with diabetes to develop an educational program to help patients recognize the early symptoms of diabetes. (Note: The educational program would not identify any specific patients without their permission).
Example: Jane complained that she did not receive appropriate health care. SPH reviewed Jane's record to evaluate the quality of care provided to Jane. SPH may also discuss Jane's care with an attorney.
4. Persons Involved in your Care
We may disclose PHI about you to a relative, close personal friend or any other person you identify if that person is in involved in your care and the information is relevant to your care. If the patient is a minor, we may disclose PHI about the minor to a parent, guardian or other person responsible for the minor except in limited circumstances. For more information on the privacy of minors' information, contact our Privacy Officer at 406-447-2566. We may also use or disclose PHI about you to a relative, another person involved in your care or possibly a disaster relief organization (such as the Red Cross) if we need to notify someone about your location or condition. You may ask us at any time not to disclose PHI about you to persons involved in your care. We will agree to your request and not disclose the information except in certain limited circumstances (such as emergencies) or if the patient is a minor. If the patient is a minor, we may or may not be able to agree to you request.
Example: Jane's husband regularly comes to SPH with Jane for her appointments and he helps her with her medication. When the provider is discussing a new medication with Jane, Jane invites her husband to come into the private room. The provider discusses the new medication with Jane and Jane's husband.
5. Required by Law
We will use and disclose PHI about you whenever we are required by law to do so. There are many state and federal laws that require us to use and disclose PHI. For example, state law requires us to report gunshot wounds and other injuries to the police and to report known or suspected child abuse or neglect. We will comply with those state laws and with all other applicable laws.
6. National Priority Uses and Disclosures
When permitted by law, we may use or disclose PHI about you without your permission for various activities that are recognized as "national priorities." In other words, the government has determined that under certain circumstances (described below), it is so important to disclose PHI that it is acceptable to disclose PHI without the individual's permission. We will only disclose PHI about you in the following circumstances when we are permitted to do so by law. Below are brief descriptions of the "national priority" activities recognized by law. For mor information on these types of disclosures, contact our Privacy Officer at 406-447-2566.
- Threat to health or safety: We may use or disclose PHI about you if we believe it is necessary to prevent or lessen a serious threat to health or safety.
- Public health activities: We may use or disclose PHI about you for public health activities. Public health activities require the use of PHI for various activities, including, but not limited to, activities related to investigating diseases, reporting child abuse and neglect, monitoring drugs or devices regulated by the Food and Drug Administration, and monitoring work-related illnesses or injuries. For example, if you have been exposed to a communicable disease (such as a sexually transmitted disease), we may report it to the State and take other actions to prevent the spead of the disease.
- Abuse, neglect or domestic violence: We may disclose PHI about you to a government authority (such as the Department of Social Services) if you are an adult and we reasonably believe that you may be a victim of abuse, neglect or domestic violence.
- Health oversight activities: We may disclose PHI about you to a health oversight agency - which is basically and agency responsible for overseeing the health care system of certain government programs. For example, a government agency may request information from us while they are investigating possible insurance fraud.
- Court proceedings: We may disclose PHI about you to a court or an officer of the court (such as an attorney). For example, we would disclose PHI about you to a court if a judge orders us to do so.
- Law enforcement: We may disclose PHI about you to a law enforcement official for specific law enforcement purposes. For example, we may disclose limited PHI about you to a police officer if the officer needs the information to help find or identify a missing person.
- Coroners and others: We may disclose PHI about you to a coroner, medical examiner, or funeral director or to organizations that help with organ, eye and tissue transplants.
- Workers' compensation: We may disclose PHI about you in order to comply with workers' compensation laws.
- Research organizations: We may use or disclose PHI about you to research organizations if the organization has satisfied certain conditions about protecting the privacy of PHI.
- Certain government functions: We amy use of disclose PHI about you for certain government functions, including but not limited to military and veterans' activities and national security and intelligence activities. We may also use or disclose PHI about you to a correctional institution in some circumstances.
Other than the uses and disclosures described above (#1-6), we will not use or disclose PHI about you without the "authorization", or signed permission, of you or your personal representative. In some instances, we may wish to use or disclose PHI about you and we may contact you to ask you to sign an authorization form. In other instances, you may contact us to ask us to disclose PHI and we will ask you to sign an authorization form. If you sign a written authorization allowing us to disclose PHI about you, you may later revoke (or cancel) you authorization in writing (except in very limited circumstances related to obtaining insurance coverage). If you would like to revoke your authorization, you may write us a letter revoking your authorization. If you revoke your authorization, we will follow your instructions except to the extent that we have already relied upon your authorization and taken some action.
The following uses and disclosures of PHI about you will only be made with your authorization (signed permission):
- Uses and disclosures for marketing purposes
- Uses and disclosures that constitute the sale of protected health information.
- Most uses and disclosures of psychotherapy notes, if we maintain psychotherapy notes.
- Any other uses and disclosures not described in this Notice.
YOU HAVE RIGHTS WITH RESPECT TO MEDICAL INFORMATION ABOU YOU
You have several rights with respect to PHI about you. This section of the Notice will briefly mention each of these rights. If you would like to know more about your rights, please contact our Privacy Officer at 406-447-2566.
1. Right to a Copy of this Notice
You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy of this Notice will be posted in our waiting area. If you would like to have a copy of our Notice, ask the receptionist for a copy or contact our Privacy Officer at 406-447-2566.
2. Right to Access to Inspect and Copy
You have the right to inspect (which means see or review) and receive a copy of PHI about you that we maintain in certain groups of records. If we maintain your medical records in an Electronic Health Record (EHR) system, you may obtain and electronic copy of your medical records. You may also instruct us in writing to send an electronic copy of your medical records to a third party. If you would like to inspect or receive a copy of PHI about you, you must provide us with a request in writing. You may submit a letter requesting access to the following address:
Helena, MT 59601
Attn: Privacy Officer
We may deny you request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. We will also inform you in writing if you have the right to have our decision reviewed by another person. If you requested a copy of PHI about you, we may charge a reasonable amount for the cost of the copies we provide you. Our fees for electronic copies of your medical records will be limited to direct labor costs associated with fulfilling your request. $5 each quarter hour. We may be able to provide you with a summary or explanation of the information. Contact our Privacy Officer for more information on these services and possible additional fees.
3. Right to Have Medical Information Amended
You have the right to have us amend (which means correct or supplement) medical information about you that we maintain in certain groups of records. If you believe that we have information that is either inaccurate or incomplete, we may amend the information to indicate the problem and notify others who have copies of the inaccurate or incomplete information. If you would like us to amend information, you must provide us with a request in writing and explain why you would like us to amend the information. Submit to: 2475 Broadway, Helena, MT 59601 Attn: Privacy Officer. We may deny you request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. You will have the opportunity to send us a statement explaining why you disagree with our decision to deny you amendment request and we will share your statement whenever we disclose the information in the future.
4. Right to Accounting of Disclosures We Have Made
You have the right to receive an accounting (which means a detailed listing) of disclosures that we have made for the previous six (6) years. If you request an accounting more than once every twelve (12) months, we may charge you a fee to cover the costs of preparing the accounting. $5.00 per quarter hour. If you would like to receive an accounting, you may send us a letter requesting an accounting by submitting the request to our Release of Information Office or the Privacy Officer.
5. Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit the use and disclosure of PHI about you for treatment, payment and heath care operations. Under federal law, we must agree to your requesst and comply with your requested restriction(s) if:
- Except as otherwise required by law, the disclosure is to a health plan for purpose of carrying out payment of health care operations (and is not for purposes of carrying out treatment); and,
- The PHI pertains soley to a health care item or service for which the health care provided involved has been paid out-of-pocket in full. Once we agree to request, we must follow your restrictions (except if the information is necessary for emergency treatment). You may cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation. You also have the right to request that we restrict disclusures of you PHI and health care treatement(s) to a health plan (health insurer) or other party, when that information relates soley to a health care item or service for which you or another person on your behalf (other that a health plan), has paid us out-of-pocket in full. Once you have requested such restrictions, and your payment in full has been we must follow your restriction(s).
6. Right to Request and Alternative Method of Contact
You have the right to request to be contacted at a different location or by a different method. For example, you may prefer to have all the written information mailed to your work address rather than to your home address. We will agree you any reasonable request for alternative methods of contact. If you wuold like to request an alternative method of contact, you must provide us with a request in writing. You may write us a letter requesting and detailing your alternative method(s) of contact at the following address:
Helena, MT 59601
Attn: Privacy Officer
7. Right to Notification in the event of a Breach of Your Protected Health Information
You also have the right to be notified in the event of a breach of your protected health information. If your protected health information is breached and if that information is unsecured, we will notify you promptly with the following information:
- A brief description of what happened;
- A description of the health information that was involved;
- Recommended steps you can take to protect youself from harm;
- What steps we are taking in response to the breach; and,
- Contact procedures so you can obtain further information.
8. Right to Opt-Out of Fundraising communications
If we conduct fundraising and we use communications like the U.S. Postal Service or electronic email for fundraising, you have the right to opt-out of receiving such communications from us. Please contact our Foundation Office to opt-out of fundraisisng communications if you choose to do so.
YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a written complaint either with us or with the federal government.
To file a written complaint with us, you may bring your complaint directly to our Privacy Officer, or you may mail it to the following address:
St. Peter's Hospital
Helena, MT 59601
Attn: Privacy Officer
The complaint must name the entity that is the subject of the complaint and describe the acts or omissions believed to be in violation of the applicable rquirements of the rule. To file a written complaint with the federal government, please use the following contact information:
Office for Civil Rights
1961 Stout Street
Denver, CO 80294-3538
Office of Civil Rights Website: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
You will not be penalized for filing a complaint, and we will not take any action against you or change our treatment of you in any way if you file a complaint.