T.J. Samson Community Hospital’s Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION.
T.J. Samson Community Hospital is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. T.J. Samson Community Hospital is required by law to abide by the terms of the Notice that is currently in effect.
ORGANIZED HEALTHCARE ARRANGEMENT
T. J. Samson Community Hospital participates in a clinically integrated care setting in which patients typically receive health care from more than one health care provider. This arrangement is called an Organized Health Care Arrangement (or OHCA) under the federal laws governing the privacy of patient health information. This means that when you receive services at T.J. Samson Community Hospital, you may receive certain professional services from physicians on our Medical Staff, residents, and/or medical students who are independent practitioners and not employees or agents of T.J. Samson Community Hospital. These independent practitioners have agreed to abide by the terms of this Notice when providing services at T.J. Samson Community Hospital. Therefore, this Notice applies to all of your health information that is created or received as a result of being a patient at T.J. Samson Community Hospital. However, this Notice does not apply to the independent practitioners in their private offices. As a result, you will also receive Notices of Privacy Practices from these independent practitioners when they provide services in their private offices.
This Notice applies to all health care professional who treat you at any of our locations. This Notice also applies to all of T.J. Samson Community Hospital’s departments and clinics whether they are located off-campus or on our campus.
HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED
Health Care Operations
We may use and disclose medical information about you to support our health care operations. For example, we may use or disclose your medical information in order for us to review our services and to evaluate our staff’s performance. We may use or disclose your medical information to obtain a medical consultation regarding your care or treatment.
We will use or disclose medical information about you for treatment purposes to doctors, nurses, technicians, and other caregivers in accordance with the medical authorization that you signed and provided to us. For example, a physician treating you for a broken leg in our facility may need to know whether you are a diabetic because diabetes slows the healing process. A nurse or diabetic counselor may discuss your medical condition with your physician.
We will use or disclose medical information about you so that the services we provide may be billed to and payment may be collected from you, an insurance company or a third party in accordance with the medical authorization that you signed and provided to us. For example, if a patient is admitted to our facility for chest pain, we will disclose the patient’s medical condition to the patient’s health plan so that the health plan will pay us or reimburse the patient for the services provided. We may also tell a patient’s health plan about a scheduled procedure in order to obtain prior approval or to determine whether the patient’s plan will cover the procedure.
We may also use and/or disclose your information in accordance with federal and state laws for the following purposes:
- Appointment Reminders. We may contact you to provide appointment reminders.
- Treatment Options. We may contact you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
- Facility Directory. Unless you object, we will include your name, location in the hospital and your religious affiliation in our directory of individuals. The directory information, except for your religious affiliation will be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, even if they do not ask for you by name, unless you object.
- Family and Friends. We may disclose your medical information to family members, other relatives or close friends when the medical information is directly relevant to that person’s involvement with your care or payment for care.
- Notification. We may use or disclose your medical information to notify a family member, a personal representative, or another person responsible for your care, of your location, general condition or death.
- Public Health Activities. We may disclose your medical information for public health purposes such as preventing disease, reporting births, deaths, child abuse, or domestic abuse, or to notify people of recall of products they may be using.
- Business Associates. We may disclose your medical information to a business associate with whom we contract to provide services on our behalf. To protect your health information, we require our business associates to appropriately safeguard the health information of our patients.
- Disaster Relief. We may disclose your medical information to a public or private entity, such as the American Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts.
- Health Oversight Activities. We may disclose your medical information to a health oversight agency for oversight activities authorized by law including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.
- National Security and Intelligence Activities. We may release your medical information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
- Legal Proceedings. We may disclose your medical information in the courses of certain judicial or administrative proceedings.
- Law Enforcement. We may disclose your medical information for certain law enforcement purposes or other specialized governmental functions.
- Coroners, Medical Examiners and Funeral Directors. We may disclose your medical information to a coroner, medical examiner or a funeral director.
- Organ Donation. If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization.
- Research. We may disclose your protected health information to researchers when authorized by law, for example, if their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
- Public Safety. We may use or disclose your medical information to prevent or lessen a serious threat to your health and safety or the health or safety of another person or to the public.
- Worker’s Compensation. We may disclose your medical information as authorized by law relating to worker’s compensation or similar programs.
As Required by Law, we may disclose medical information about you when required to do so by federal, state or local law.
We will not use or disclose your medical information for any other purpose not covered by this Notice without your written authorization. Once given, you may revoke your authorization in writing at any time. To request a Revocation of Authorization form, you may contact:
T.J. Samson Community Hospital
Health Information Department
1301 North Race
Glasgow, KY 42141
SECURITY OF INFORMATION
We use our best efforts to ensure the security of personal information submitted by users. When collecting credit card information for online purchases, we offer secured-server transactions that encrypt your information in transit to thwart someone from intercepting it and misusing it. When we collect other information from our users, it is stored in an area where the general public does not have access to it. T.J. Samson furthermore does not store credit card numbers at it's facility.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights with respect to your medical information:
- RIGHT TO INSPECT AND COPY. You have the right to inspect and receive copies of your medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. We will respond to your request within thirty (30) days of the request or sixty (60) days if your medical information is not available on site. We shall be granted a thirty (30) day extension upon written notice to you providing the reason for the extension of time.
- Fees. There may be a fee for copies of your record; you will be notified before any charges are applied. The first requested copy is free; there will be a charge of $1.00 per page for subsequent copies.
- Denials. We may deny your request to inspect and/or receive copies of your medical information if it is not in writing and in other, very limited circumstances. You will receive a written notice of denial containing the reason for denial and the procedure for review. In some circumstances, another licensed health care professional chosen by T.J. Samson Community Hospital may 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. However, in some circumstances, our denial of a request by you to inspect and/or receive copies of your information is not subject to review.
- RIGHT TO AMEND. If you feel that medical information we have about you is incorrect or incomplete, 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, T.J. Samson Community Hospital. In your written request, you must provide a reason that supports your request for amendment. If we approve your request, we shall make the amendment to your medical information, inform you that we have made the amendment, and make a reasonable effort to tell others that need to know about the change to your medical information Send request to: Sharon Bybee, Chief Privacy Officer at T.J. Samson Community Hospital 1301 North Race, Glasgow KY 42141.
- Denials. 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 us, unless the person or entity that created the information is no longer available to make the amendment.
- Is not part of the medical information kept for or by T.J. Samson Community Hospital.
- Is not part of the information which you would be permitted to inspect and copy.
- Is accurate and complete.
- If your request for amendment is denied, we will provide you with a written statement of the basis for the denial and a description of how you may file a written statement of disagreement. If you do not file a statement of disagreement, you may request that your request for amendment and our written denial be provided with any future disclosures of your medical information.
- 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 regarding medical information about you.
- Exclusions. The
list will not include: disclosures made for
treatment, payment, or health care operations; disclosures
made directly to you; disclosures authorized
by you pursuant to a signed authorization; disclosures
made for national security or intelligence
purposes; and disclosures to correctional institutions
and for other law enforcement purposes. The list also
will not include disclosures made before
April 14, 2006. Your request must include a time period,
which may not exceed six (6) years prior
to the date of the request and may not include any
dates prior to April 14, 2006.
- Your request should also indicate in what form, i.e., electronic or paper, you would like your request to be processed. We will provide the first list to you at no charge, however if you make more than one request in the same year, we may charge you up to $1.00 per page for each additional request. 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 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 a limit on the medical information we disclose about you to someone who is involved in your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. However, we are not required to grant your request. If we do grant your request, we will comply with your request unless the information is needed to provide you emergency medical treatment. In your request, tell us, (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
- 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 request that we only contact you at work or by mail. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- RIGHT TO PAPER COPY OF THIS NOTICE. You may request a paper copy of this Notice at any time. If you would like to inspect, amend or copy your medical information, receive an accounting of disclosures of your medical information, or to request a restriction on your medical information, please submit your request and reason in writing.
T.J. Samson Community Hospital
Sharon Bybee, Chief Privacy Officer
1301 North Race
Glasgow, KY 42141
You have the right to complain to us and/or the United States Department of Health and Human Services if you believe that we have violated your right to privacy. If you choose to file a complaint, you will not be retaliated against in any way. To complain to us or to contact us for additional information about this Notice or our privacy practices, please contact:
Debbie London, Patient Advocate
1303 North Race
Glasgow, KY 42141
REVISION OF NOTICE OF PRIVACY PRACTICES
We reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at T.J. Samson Community Hospital and on our website and we will make paper copies of the revised Notice of Privacy Practices available upon request.