Privacy Notice
NOTICE OF PRIVACY PRACTICES OF GUTTENBERG MUNICIPAL HOSPITAL AND ITS ORGANIZED HEALTH CARE ARRANGEMENT
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 is the Privacy Notice of Guttenberg Municipal Hospital, Guttenberg, Iowa and its Organized Health Care Arrangement. This notice applies to (1) all employees, staff, volunteers and other personnel of Guttenberg Municipal Hospital, and (2) the physicians and other practitioners who are not employed by Guttenberg Municipal Hospital, but who have privileges to treat patients there and who are members of its Organized Health Care Arrangement. (See description of Organized Health Care Arrangement on page 3.)
We are required by law to maintain the privacy of your medical information (Protected Health Information -"PHI"), and to give you our Notice of Privacy Practices. This Notice describes the ways in which we may use and disclose your medical information to carry out treatment, payment and health care operations, and for other purposes as permitted or required by law. It also describes your rights and our legal duties regarding the use and disclosure of your medical information.
HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe different ways that we may use and disclose your medical information without your written authorization (permission). We have tried to give some examples of each of the different types of disclosures, but not every use or disclosure in a category will be listed.
Treatment. We may use and disclose your medical information to provide you with medical treatment or related services. (e.g., provide information to doctors, nurses, technicians, students or other personnel who are involved in your care, coordinate care and make referrals to other providers).
Payment. We may use and disclose your medical information in order to collect payment from you, an insurance company, or a third party for the treatment and services you receive (e.g., verifying eligibility or coverage with your insurance company, submitting a claim to your insurance company, making a credit report).
Health Care Operations. We may use and disclose your medical information for our facilities health care operations. These uses and disclosures are necessary for our business and to make sure our patients are receiving quality service (e.g., to evaluate our staff and internal processes.) In addition, as part of our operations, certain limited information may be used or disclosed to conduct fundraising activities on our behalf. You have the right to request that you not receive fundraising materials from us.
Appointments and Health Care Services. We may use and disclose your medical information to provide you with appointment reminders, or to notify you of possible treatment alternatives or health-related benefits or services.
Facility Directory. While you are a patient at GMH, your name, location in the Facility, general condition (e.g., fair, stable, etc.), and religious affiliation may be included in the Facility Directory and released (except religious affiliation) to people who ask for you by name. This information and your religious affiliation may be given to a member of the clergy, even if they do not ask for you by name. You have the right to request that your name not be included in the directory.
Friends and Family. We may disclose your medical information to a friend or family member involved in your medical care or payment for your care. If you are available, such disclosures will be made only if we have obtained your permission, or if you do not object to the disclosure after having the opportunity, or if it is reasonable for us, based on the circumstances, to assume you have no objection to such disclosure. If you are unavailable, incapacitated or in an emergency situation, we may disclose limited information to these persons if we determine disclosure is in your best interest.
Health Care Providers. We may disclose your medical information to another health care provider involved in your treatment or medical care in order for them to treat you, bill for their services and conduct their health care operations.
Disaster Relief. We may disclose your medical information to a public or private entity assisting in a disaster relief effort (e.g., to notify your family about your location, condition or death).
Public Health Activities. As permitted or required by law, we may disclose your medical information to public health authorities that receive information to: prevent or control disease, injury or disability, report births and deaths; report child abuse or neglect; and notify those who may be at risk for communicable diseases.
Abuse, Neglect and Domestic Violence. We may notify the appropriate government authority if we believe you have been the victim of abuse, neglect or domestic violence. Unless required by law, we will only make this disclosure if you agree. We may make this disclosure under other limited circumstances when such disclosure is authorized by law.
Health Safety Risks. We may use and disclose your medical information under certain circumstances, when necessary to prevent a serious threat to your health and safety, or to the health and safety of the public or another person.
Organ Donations. We may disclose your medical information to organ procurement or organ, eye or tissue transplantation organizations, or to organ donation banks to facilitate organ or tissue donation and transplantation.
Military and National Security. If you are a member of the armed forces, we may disclose your medical information as required by military command authorities, or with regard to foreign military personnel, to the appropriate foreign military authority. We may also release your medical information to authorized federal officials for intelligence, counterintelligence, and other authorized national security activities.
Worker's Compensation. We may release your medical information to employers, insurance carriers, attorneys, or others as required in order to comply with worker's compensation laws or other similar programs providing benefits for work-related injuries.
Health Oversight Activities. We may disclose your medical information to a health oversight agency for activities authorized by law to monitor the health care system, government programs and compliance with civil rights laws (e.g., fraud and abuse investigations, inspections and licensure, or disciplinary actions).
Legal Proceedings. If you are involved in a lawsuit or dispute, we may disclose your medical information in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena or other lawful process by someone else involved in the dispute, but only if the party seeking the information demonstrates that reasonable efforts have been made to notify you of the request or to obtain a protective order from the court.
Law Enforcement. We may disclose your medical information to law enforcement authorities for law enforcement purposes, such as (1) in response to a court order, subpoena, warrant, summons or similar process, (2) to identify or locate a suspect, fugitive, material witness or missing persons, (3) if you are the victim of a crime, but only if your agreement is obtained or, under certain limited circumstances if we are unable to obtain your agreement, (4) about a death which is believed to be the result of criminal conduct, (5) to report a crime that occurred on our premises, and (6) 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. We will comply with Federal and State laws in making such disclosures.
Deceased Individuals. We may release your medical information to a coroner or medical examiner (e.g., to identify a deceased person or determine the cause of death), or to funeral directors as necessary to carry out their duties.
Correctional Institutions. We may release your medical information to the correctional institution where you are an inmate or to a law enforcement official who has custody of you for certain limited purposes (e.g., to provide you with health care).
Research. We may use and disclose your medical information for research-related activities that meet all privacy law requirements.
Limited Medical Information. We may release limited medical information about you to a third party for research purposes, public health activities and our health care operations. The party to whom we disclose the information is required to keep it confidential.
Required by Law. We will disclose your medical information when required to do so by federal, state or local law (e.g., to report child or dependent adult abuse and violent wounds).
Incidental Disclosures. Occasional incidental, unintended disclosures of your medical information may occur during a permitted use or disclosure such as information overheard during a discussion regarding your care with you or a member of your family. We will take reasonable steps to limit these types of disclosures.
Business Associates. Some of the activities described above are performed through contracts with outside persons or organizations ("business associates"), such as legal services. It may be necessary for us to provide some of your medical information to these business associates who assist us with these activities. We require that our business associates appropriately safeguard the privacy of your information.
ORGANIZED HEALTH CARE ARRANGEMENT
Guttenberg Municipal Hospital is a clinically integrated care setting where patients receive care from Hospital personnel and from independent doctors and other practitioners who provide care to patients at our facility (collectively called "practitioners"). Information needs to be shared freely between us (the Hospital and these practitioners) to provide care to our patients, and to conduct our health care operations. Therefore, Guttenberg Municipal Hospital and the practitioners have agreed to follow uniform information practices when using or disclosing medical information related to inpatient or outpatient hospital services. This arrangement is called an "Organized Health Care Arrangement" and only covers information practices for services rendered through Guttenberg Hospital. It does not cover the information practices of the practitioners in their offices or at other care settings. It does not alter the independent status of the Hospital and the practitioners or make them jointly responsible for the clinical services provided by them. In other words, the Hospital is not responsible for (1) the negligence (or mistakes) of the independent practitioners providing care there; or (2) any violations of your privacy rights by the independent practitioners.
YOUR RIGHTS
Uses and disclosures of your medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization (permission).
Right to Revoke Authorization. You have the right to revoke (take back) in writing at any time, your authorization that gave us permission to use or disclose your medical information that is not otherwise covered by this notice or applicable law. If you revoke your authorization, we will no longer use or disclose your medical information for the reasons set forth in your written authorization. We are, however, unable to take back any disclosures we have already made with your authorization.
Right to Access Medical Information. You may request to inspect and copy much of the medical information we maintain about you. This includes most medical and billing records with some exceptions. It does not include psychotherapy notes. If you request a copy of this information, we may charge a fee for the costs of copying, mailing, and other supplies associated with your request.
Right to Request Restrictions. You have the right to request a restriction on how we use or disclose your medical information for treatment, payment, or health care operations, or to certain family members or friends identified by you who are involved in your care or the payment for your care. We are not required to agree to your request, but will notify you if we are unable to agree.
Right to Amend. You may request that we amend your medical information if you believe that it is incorrect or incomplete. We are not required to make all requested amendments, but we will give each request careful consideration. If we deny your request, we will provide you with a written explanation of the reason and your rights.
Right to Request an Accounting. You have the right to receive a list of certain disclosures of your medical information made by us or our business associates. This right applies to disclosures for purposes other than treatment, payment, healthcare operations, or as otherwise permitted or required by law. You must state a time period for your request, which may not be longer than six years and may not include dates before April 14, 2003. The first list in any 12-month period will be provided to you for free; for each subsequent list you request within the same 12-month period, you may be charged a fee.
Right to Confidential Communications. You have the right to request that we communicate information about your health to you by alternate means or at a different location. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to This Notice. You have the right to obtain a copy of this notice at any time. If you receive this Notice by electronic mail (e-mail), you are entitled to receive and may request a printed copy of this Notice.
HOW TO EXERCISE THESE RIGHTS
Your request to exercise any of these rights must be in writing. We will follow written policies to handle your request, and we will notify you of our decision or actions and your rights. You can obtain Request forms from us at the address below.
Complaints. If you believe your privacy rights have been violated, you may file a complaint with our privacy officer at the address below. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint.
Questions. If you have questions regarding your privacy rights, please contact us at the address below.
CHANGES TO THIS NOTICE
We are required to abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this Notice and make the new Notice provisions effective for all of your medical information that we maintain, including that which was created or received while the prior Notice was in effect. If we make a material change to our privacy practices, we will amend our Notice and post the revised Notice in our facility. The effective date will be reflected on the Notice.
FOR MORE INFORMATION Contact Privacy Officer:
Bren Lowe
Guttenberg Municipal Hospital
200 Main St., PO Box 550
Guttenberg, IA 52052
Phone: 563-252-1121
Revised Date: August 10, 2007 Version: 02
Effective Date: April 14, 2003 Version: 01