Prague Community Hospital

NOTICE OF PRIVACY PRACTICES

Effective April 14, 2003

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.

Prague Community Hospital is committed to protecting your medical information. We are required by law to:

?Maintain the privacy of your medical information;

?Give you a notice of our legal duties and privacy practices with respect to your medical information; and

? Follow the terms of the notice currently in effect.

What is this document?

This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information. It also describes your rights to access and control your Protected Health Information.

What does this Notice cover?

This Notice of Privacy Practices applies to all of your Protected Health Information used to make decisions about your care that we generate or maintain.  Different privacy practices may apply to your protected health information that is created or kept by other people or entities.

Prague Community Hospital, its medical staff, and other health care providers are creating a clinically integrated care setting and constitute an organized health care arrangement under HIPAA.  You may receive another NPP from physician, other health care providers and other entities upon your first encounter with them, which may be different from this NPP and which will govern the Protected Health Information maintained by that provider.  These physicians and health care providers will be able to access and use your Protected Health Information to carry out treatment, payment or health care operations throughout this organized health care arrangement.

Who does this Notice cover?

This Notice of Privacy Practices will be followed by:

?All employees, departments and units of the Facility;

?Any health care professional who treats you at the Facility or who is a member of our organized health care arrangement;

?Any member of a volunteer group that provides help to patients;

?Any member of the Home Health Agency; and

?  Any member involved in long term care

What will you do with my protected health information?

The following categories describe the ways that we may use and disclose your protected health information without your authorization.  Not every use or disclosure in a category will be listed.

If you are concerned about a possible use or disclosure of any part of your protected health information, you may request a restriction. Your right to request a restriction is described in the section regarding patient rights on the following pages.

Treatment.  We will use your protected health information to provide you with medical treatment and services. 

Examples: (1) Your protected health information may be disclosed to doctors, nurses, technicians, students, or other facility personnel who are involved in your care.

(2) Different departments of the Facility also may share protected health information about you in order to coordinate specific services, such as prescriptions, lab work and x-rays.

We may disclose your protected health information for the treatment activities of any other health care providers. 

Examples:  (1) We may send a copy of your medical record to a physician who needs to provide follow-up care.  (2) We may send a copy of your health care instructions to a nursing home to which you have been transferred to facilitate coordination of care.

Payment.  We may use protected health information about you for our payment activities. Common payment activities include, but are not limited to:

?      Determining eligibility or coverage under a health plan;

?      Billing and collection.

Examples: (1) Your protected health information may be shared with an insurance company to obtain payment for services.  (2) We may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

We may disclose protected health information about you to another health care provider or covered entity for its payment activities.

Examples:  (1) We may send your health plan coverage information to an outside laboratory that needs the information to bill for tests that it provided to you. (2) We may provide physicians or their billing agents with information so they can send bills to your insurance or to you.

Health Care Operations.  We may use your protected health information for facility operations.  These uses are necessary to run the Facility and to make sure patients receive quality care.  Common operation activities include, but are not limited to:

?    Conducting quality assessment and improvement activities

?    Reviewing the competence of health care professionals

?    Training health care professionals

?    Arranging for legal or auditing services

?    Business planning and development

?    Business management and administrative activities and

?    Communicating with patients about Facility services.

Examples: (1) We may use your protected health information to conduct internal audits to verify that billing is being conducted properly. 

(2) We may use your protected health information to contact you for the purposes of conducting patient satisfaction surveys or to follow-up on the services we provided. 

We may disclose protected health information about you to another health care provider or covered entity for its operation activities under certain circumstances.

Example:  We may disclose your protected health information to your health plan for its utilization review analysis. 

Business Associates.  We may disclose your protected health information to other entities that provide a service to us or on our behalf that requires the release of patient protected health information.    We will only make these disclosures if we have received satisfactory assurance that the other entity will properly safeguard your medical information.

Example:  We may contract with another entity to provide transcription or billing services.

Treatment Alternatives.  We may use and disclose your protected health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care.  We may release protected health information about you to a friend, family member or legal guardian who is involved in your medical care or who helps pay for your care.  In addition, we may disclose protected health 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.

Appointment Reminders.  We may use and disclose protected health information to contact you as a reminder that you have an appointment for medical treatment or services at the facility.  This may be done through an automated system or by one of our staff members.  If you are not at home, we may leave this information on your answering machine or in a message left with the person answering the telephone.

Health-Related Benefits and Services.  We may use and disclose protected health information to tell you about health-related benefits or services that may be of interest to you. 

Patient Directory.  We may include certain limited information about you in the facility’s patient directory while you are a patient in the Facility.  Your location in the Facility, your general condition (e.g., fair, good, etc) and your religious affiliation may be released to people who ask for you by name.  This information may also be given to a member of the clergy, such as a minister, priest or rabbi, even if they don’t ask for you by name.  This is so your family, friends and clergy can visit you in the Facility and generally know how you are doing.  If you do not want to be in our directory, you will need to notify hospital personnel at registration.  You will be asked to complete a “Request for Restriction Form”. 

Research.  Under certain circumstances, we may use and disclose protected health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.  All research projects are subject to a special approval process.  This process evaluates a proposed research project and its use of protected health information, trying to balance the research needs with the patient’s need for privacy of their protected health information.  Before we use or disclose protected health information for research, the project will have been approved through this research approval process.

Example:  We may disclose protected health information about you to people preparing to conduct a research project to help them look for patients with specific medical needs, as long as the protected health information does not leave the facility.  We may ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are.  Protected health information regarding people who have died can be used or disclosed without authorization under certain circumstances. 

Organ and Tissue Donation. If you are an organ donor, we may disclose protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Fundraising Activities of the Facility.  We may use protected health information about you to contact you in the future to raise money for the Facility.  We may disclose protected health information to a foundation related to the Facility so that the foundation may contact you to raise money on our behalf.  We only will release contact information, such as your name, address and phone number and the dates you received treatment or services at the Facility for fundraising purposes.  If you do not want us, or a related foundation, to contact you for fundraising efforts, you must notify our Privacy Official in writing by regular mail. 

Can you ever use and disclose my protected health information without my authorization or opportunity to restrict? Yes. 

The following categories describe the ways that we may be required to disclose your protected health information without your authorization. Not every disclosure in a category will be listed.

Required by Law.  We will disclose protected health information about you when required to do so by federal, state or local law.

Examples:  (1) Oklahoma law requires us to report all births and deaths that occur in the facility to the Oklahoma Department of Health. (2) We are required by law to report criminally inflicted injuries and cases of abuse and neglect. These reports may include your protected health information.

Public Safety.  We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Any disclosure would only be to someone able to help prevent the threat.

Public Health Reporting.  We may disclose protected health information about you for public health activities, for example:

?Prevent or control disease, injury or disability;

?Report births defects or infant eye infections;

? Report a victim of abuse, neglect or domestic abuse, as required by   law;

?Report reactions to medications or problems with products;

?Notify people of recalls of products they may be using;

?Notify the Oklahoma State Department of Health that a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition such as HIV, Syphilis, or other sexually transmitted diseases; or

?Report cancer diagnoses and tumors.                        

Food and Drug Administration (FDA).  We may disclose to the FDA and to manufacturers protected health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacements.

Health Oversight Activities.  We may disclose protected health information to a health oversight agency for activities necessary for the government to monitor the health care system, government programs, and compliance with applicable laws. These oversight activities include, for example, audits, investigations, inspections, medical device reporting and licensure. 

Example:  We may be required to disclose patient protected health information to the Oklahoma State Department of Health to maintain our facility license.

Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court or administrative order.  In limited circumstances, we may disclose protected health information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to inform you about the request or to obtain an order protecting the information requested.

Law Enforcement.  We may disclose protected health information if asked to do so by a law enforcement official:

?    In response to a court order, warrant, summons or other similar process;

?    To identify or locate a suspect, fugitive, material witness, or missing person;

?    About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;

?    About a death we believe may be the result of criminal conduct;

?    About criminal conduct at the facility; and

?    In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.        

Coroners, Medical Examiners and Funeral Directors. We may disclose protected health information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may disclose protected health information about patients of the facility to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may disclose protected health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others.  We may disclose protected health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. 

Military/Veterans.  If you are a member of the armed forces, we may disclose protected health information about you as required by military command authorities.  We may also disclose protected health information about foreign military personnel to the appropriate foreign military authority.

Inmates.  If you are an inmate of a correctional facility or under the custody of law enforcement official or agency, we may disclose protected health information about you to the correctional facility or law enforcement official or agency.  This release may be necessary to: (1) enable the correctional facility to provide you with health care; or (2) to protect the health and safety of you and/or other people, or (3) to protect the safety and security of the correctional institution.

Worker’s Compensation.  We may disclose protected health information about you for workers’ compensation or similar programs as authorized by state laws.  These programs provide benefits for work-related injuries or illnesses.

What if you want to use and/or disclose my protected health information for a purpose not described in this Notice?

We must obtain a separate, specific authorization from you to use and/or disclose your protected health information for any purpose not covered by this notice or by the laws that apply to us. If you provide us with authorization to use or disclose your protected health information, you may revoke the authorization, in writing, at any time. If you revoke your authorization, we will not use or disclose your protected health information for the reasons covered by your authorization.  However, your revocation will not apply to disclosures already made by us in reliance on your authorization.

What are my rights regarding my protected health information?

You have the rights described below in regard to the protected health information that we maintain about you.  You are required to submit a written request to exercise any of these rights.  You may contact our Privacy Official to obtain a form that you can use to exercise any of the rights listed below.

Right to Inspect and Copy.  You have the right to inspect and request a copy of your protected health information, except as prohibited by law.  To inspect and/or request a copy of your protected health information that may be used to make decisions about you, you must submit your request in writing.  If you request a copy of the information, we may charge a per page fee to offset the costs associated with the request.  This fee will be explained before copies are made to give you an opportunity to withdraw your request. 

We may deny your request to inspect and copy in certain circumstances. If you are denied access to certain protected health information, you may request that the denial be reviewed.  Another licensed health care professional chosen by the facility will review your request and the denial.  The person conducting the review will not be the person who denied your original request.  We will comply with the outcome of the review.

Right to Amend.  If you feel that protected health information that we created is incorrect or incomplete, you may submit a request for an amendment for as long as we maintain the information. To request an amendment, your request must be made in writing that states the reason for the 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 to amend information that:

?    Was not created by us, unless the person or entity that created the information is not available to make the amendment

?    Is not part of the protected health information that we maintain or that is kept for us

?    Is not part of the information that you would be permitted to inspect and copy or

?    Is accurate and complete.

Right to an Accounting of Disclosures.  You have the right to request one free accounting every 12 months of the disclosures we made of protected health information about you. To request this list, you must submit your request in writing.  Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, on paper or electronically).  For additional lists during a 12 month period, we may charge you for the costs of providing the list.  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. For example, we do not have to keep track of disclosures made for treatment, payment or health care operations or for those disclosures that are authorized.

Right to Request Restrictions.  You have the right to request a restriction or limitation on the protected health 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 protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose directory information.

We are not required to agree to your request.  If we agree, we will comply with your request unless the information is needed to provide emergency treatment to you.

To request restrictions, you must make your request in writing. 

In your request, you must tell us:

?      What information you want to limit;

?  Whether you want to limit our use, disclosure or both

?  To whom you want the limits to apply.

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 can ask that we only contact you at work or by mail. 

To request confidential communications, you must make your request in writing.  We will not ask you for the reason for the request.  We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice.  You have the right to a paper copy of this notice.  Copies of this notice will always be available in our Admissions department.  You may also obtain a copy of this notice at the following website address: www.praguehospital.com.

Can we change this notice?

We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for protected health information we already have about you as well as any information we receive in the future.  Copies of the current notice will be posted at the Facility and will be available for you to pick up on each visit to the Facility.  The effective date will be displayed on the front page. 

What if I have questions or need to report a problem?

If you believe your privacy rights have been violated, you may file a written complaint with Prague Community Hospital or with the Secretary of the Department of Health and Human Services. 

To file a complaint with the Facility or if you would like more information about our privacy practices, contact our Privacy Official, Krista Grooms, RHIA at (405) 567-4922 x252. The Privacy Official’s mailing address is:

Krista Grooms, RHIA

Prague Community Hospital

P.O. Drawer S

Prague, OK  74864

To file a complaint with the Secretary of the Department of Health and Human Services, you must submit the complaint within 180 days of when you knew or should have known of the circumstance that led to the complaint.  The complaint must be submitted in writing either on paper or electronically.  Name the entity that is the subject of the complaint and describe the acts or omissions believed to be in violation of the standards. 

Region VI, Office for Civil Rights

U.S. Department of Health and Human Services

1301 Young Street, Suite 1169

Dallas, TX 75202