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.
This notice takes effect on
___________ and remains in effect until we replace it.
1. OUR PLEDGE REAGRDING MEDICAL
The privacy of your medical
information is important to us. We understand that your medical
information is personal and we are committed to protecting it.
We create a record of the care and services you receive at our
organization. We need this record to provide you with quality
care and to comply with certain legal requirements. This notice
will tell you about the ways we may use and share medical information
about you. We also describe your rights and certain duties we
have regarding the use and disclosure of medical information.
2. OUR LEGAL DUTY
Law Requires Us to:
1. Keep your medical information private.
2. Give you this notice describing our legal duties, privacy
practices, and your rights regarding your medical information.
3. Follow the terms of the notice that is now in effect.
We Have the Right to:
1. Change our privacy practices and the terms of this notice
at any time, provided that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms
of our notice effective for all medical information that we keep,
including information previously created or received before the
Notice of Change to Privacy
1. Before we make an important change in our privacy practices,
we will change this notice and make the new notice available
3. USE AND DISCLOSURE OF
YOUR MEDICAL INFORMTATION
The following section describes
different ways that we use and disclose medical information.
Not every use or disclosure will be listed. However, we have
listed all of the different ways we are permitted to use and
disclose medical information. We will not use or disclose your
medical information for any purpose not listed below, without
your specific written authorization. Any specific written authorization
you provide may be revoked at any time by writing to us.
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, medical students, or other people who are taking
care of you. We may also share medical information about you
to your other health care providers to assist them in treating
We may use and disclose your
medical information for payment purposes.
FOR HEALTH CARE OPERATIONS:
We may use and disclose your
medical information for our health care operations. This might
include measuring and improving quality, evaluating the performance
of employees, conducting training programs, and getting the accreditation,
certificates, licenses and credentials we need to serve you.
NOTICE OF PRIVACY PRACTICES
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical
information for treatment, payment, and health care operations,
we may use and disclose medical information for the following
Facility Directory: Unless you notify us that you object, the following
medical information about you will be placed in our facilities'
directories: your name; your location in our facility; your condition
described in general terms; your religious affiliation, if any.
We may disclose this information to members of the clergy or,
except for your religious affiliation, to others who contact
us and ask for information about you by name.
Notification: Medical information to notify or help notify:
a family member, your personal representative or another person
responsible for your care. We will share information about your
location, general condition, or death. If you are present, we
will get your permission if possible before we share, or give
you the opportunity to refuse permission. in case of emergency,
and if you are not able to give or refuse permission, we will
share only the health information that is directly necessary
for your health care, according to our professional judgment.
We will also use our professional judgment to make decisions
in your best interest about allowing someone to pick up medicine,
medical supplies, x-ray or medical information for you.
Disaster Relief: Medical information with a public or private organization
or person who can legally assist in disaster relief efforts.
Fundraising: We may provide medical information to one of our
affiliated fundraising foundations to contact you for fundraising
purposes. We will limit our use and sharing to information that
describes you in general, not personal, terms and the dates of
your health care. in any fundraising materials, we will provide
you a description of how you may choose not to receive future
Research in Limited Circumstances: Medical information for research purposes in limited
circumstances where the research has been approved by a review
board that has reviewed the research proposal and established
protocols to ensure the privacy of medical information.
Funeral Director, Coroner,
Medical Examiner: To help them
carry out their duties, we may share the medical information
of a person who has died with a coroner, medical examiner, funeral
director, or an organ procurement organization.
Specialized Government Functions: Subject to certain requirements, we may disclose
or use health information for military personnel and veterans,
for national security and intelligence activities, for protective
services for the President and others, for medical suitability
determinations for the Department of State, for correctional
institutions and other law enforcement custodial situations,
and for government programs providing public benefits.
Court Orders and Judicial
and Administrative Proceedings: We
may disclose medical information in response to a court or administrative
order, subpoena, discovery request, or other [awful process,
under certain circumstances. Under limited circumstances, such
as a court order, warrant, or grand jury subpoena, we may share
your medical information with law enforcement officials. We may
share limited information with a law enforcement official concerning
the medical information of a suspect, fugitive, material witness,
crime victim or missing person. We may share the medical information
of an inmate or other person in lawful custody with a law enforcement
official or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may disclose your medical
information to public health or legal authorities charged with
preventing or controlling disease, injury or disability, including
child abuse or neglect. We may also disclose your medical information
to persons subject to jurisdiction of the Food and Drug Administration
for purposes of reporting adverse events associated with product
defects or problems, to enable product recalls, repairs or replacements,
to track products, or to conduct activities required by the Food
and Drug Administration. We may also, when we are authorized
by law to do so, notify a person who may have been exposed to
a communicable disease or otherwise be at risk of contracting
or spreading a disease or condition.