Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES

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

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your protected health information. "Protected health information" (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. We are also required to give you this notice about our privacy practices, our legal duties and your rights concerning your PHI. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until 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 law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all PHI that we maintain, including PHI we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We use and disclose PHI about you for treatment,  payment,  and health care operations. The following are examples of the types of uses and disclosures that we are permitted to make.

Treatment: We may use or disclose your PHI to a physician or other healthcare provider providing treatment to you.

Payment: We may use or disclose your PHI to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your PHI in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: You may give us written authorization to use your PHI or to disclose it to anyone for any purpose. If you give us an authorization, you may withdraw it in writing at any time. Your withdrawal will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Your Family and Friends: We must disclose your PHI to you, as described in the Patient Rights section of this Notice. We may disclose your PHI to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Your Care: We may use or disclose PHI to notify, or assist in the notification of (including identifying and locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your PHI, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose PHI based on a determination using our professional judgment disclosing only PHI that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.

Marketing: We will not use your PHI for marketing communication without your written authorization. The only exception to this is a general mailing to all current and past patients of Union County Health Center.

Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations. At times, your PHI will be disclosed to these Business Associates for the purpose of your treatment, payment or for healthcare operations.

Appointment Reminders: We may use or disclose your PHI to provide you with appointment reminders (such as phone or voicemail messages or sealed letters).

Other Uses and Disclosures: We may make certain other uses and disclosures of your PHI without your authorization.

  • We may use or disclose your PHI as required by law.
  • We may disclose your PHI for public health activities, such as reporting of disease, injury, birth and death, and for public health investigations.
  • We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may also disclose your PHI if we believe you to be a victim of abuse, neglect or domestic violence.
  • We may disclose your PHI if authorized by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings.
  • We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to respond to a subpoena or discovery request).
  • We may disclose your PHI to the proper authorities for law enforcement purposes.
  • We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent with the law.
  • We may use or disclose your PHI for cadaveric organ, eye or tissue donation.
  • We may use or disclose your PHI for research purposes, but only as permitted by law. We may use or disclose your PHI to avert a serious threat to health or safety.
  • We may use or disclose your PHI if you are a member of the military as required by armed forces services, and we may also disclose your PHI for other specialized government functions such as national security or intelligence activities.
  • We may disclose your PHI to workers' compensation agencies for your workers' compensation benefit determination.
  • We will, if required by law, release your PHI to the Secretary of the Department of Health and Human Services for enforcement of HIPAA

PATIENT RIGHTS

Access to your PHI: You have the right to look at or get copies of your PHI, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your PHI. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable, cost-based fee for expenses such as copies, staff time and postage. If we deny your request, we will provide you a written explanation and will tell you if the reasons for the denial can be reviewed and how to ask for such a review or if the denial cannot be reviewed.

Disclosure Accounting: You have the right to receive a list of instances since April 14, 2003, in which we or our business associates disclosed your PHI for purposes other than treatment, payment, health care operations, or as authorized by you, and for certain other activities. If you request this accounting more than once in a  12 month period, we  may charge you a reasonable, cost based fee for responding to these additional requests. We will provide you with more information on our fee structure at the time of your request.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is in writing.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right, with limited exceptions, to request that we amend your PHI. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we deny your request, we will provide you a written explanation. If we accept your request to amend your PHI, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Right to a Copy of the Notice: You may request a copy of our notice at any time by contacting the Privacy Office. If you receive this notice by electronic mail (e-mail), you are also entitled to request a paper copy of the notice.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice. If you are concerned that we may have violated your privacy rights or you disagree with a decision we made regarding your PHI, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. If you request, we will provide you with the address to file your complaint with the U.S. Department of Health and Human Services.

We support your right to the privacy of your PHI. 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.

Contact:

Privacy Officer or Administrator
Union County Health Center
300 Wilson St.
Clayton, NM 88415
575-374-2273

Acknowledgement of Privacy Notice

I acknowledge that I have received or been offered a copy of Union County Health Center and Affiliates Patient Privacy Notice.

____ave received a copy of Union County General Hospital and Affiliates Patient Privacy Notice. _________________________________________ __PATADMIT__

Patient or Legally Authorized Individual Signature       Date

__PATNAME__

Patients Name if signed on behalf of patient

Documentation of Good Faith Efforts to Obtain
Acknowledge of Privacy Notice

Patient Name: PATNAME         Date:  PATADMIT

The patient presented at the hospital/office and was provided with a copy of the Patient Privacy Notice. A good faith effort was made to obtain from the patient or the patient’s representative written acknowledgement of his/her receipt of the notice. Acknowledgement was not obtained because:

Patient refused to sign.
Patient’s representative refused to sign
Patient was unable to sign because: _____________________________________________________
Patient had a medical emergency and an attempt to obtain Acknowledgement will be made on the next available opportunity.
Other reason (please describe): ________________________________________________________

Employee Name: DICTNAME                                Date: PATADMIT

Terms and Conditions - Privacy Policy