HIPAA/PRIVACY POLICY

 
 
 
The Health Insurance Portability and Accountability Act (HIPAA) requires that health care providers inform patients of their rights regarding how the provider may use and disclose protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Privacy Notice describes our privacy practices that relate to your protected health information. It also describes your rights to access and control your protected health information in some cases. Your "protected health information" means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present, or future physical or mental health or condition.

Your Health Record and Protected Health Information

Each time you receive medical care from a physician, surgical center, hospital, or other healthcare provider, a record of your visit is created. This record typically includes, but is not limited to, information such as your name, age, address, a history of your illness, injury or symptoms, test results, x-rays, laboratory work, treatment, treatment plans devised for your care, and notes on follow-up care to be performed. How your health information may be used and what controls you may exercise over the use of your healthcare information is described in this Privacy Notice.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION

Twin Lakes Regional Medical Center (thereafter, the facility) may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the Facility has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA privacy regulations, state, or local law.

Who Will Follow This Notice

Twin Lakes is acting as an organized health care arrangement ("OHCA") with other health care providers who provide services to you at the Facility. The following groups are included in the OHCA, which means that they may share information as necessary to carry out treatment, payment or health care operations, but have agreed to abide by the terms of this Notice with respect to protected health information created or received at the Facility:

• Any health care professional authorized to enter information into your medical chart;

• All departments and units of the Facility;

• All employees, staff, contractors and other Facility personnel;

• All members of the Facility’s medical staff who have privileges to treat you at the Facility.
This Notice only addresses the privacy standards and practices for health care providers when treating you at the Facility. Your personal physician may have different policies or privacy notices regarding his or her use and disclosure of information created in the physician’s office or clinic.
 
Treatment
 
We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with anesthesia providers, nurses, technicians, lab personnel, radiology personnel, other facility staff involved in your care, or a third party for treatment purposes. For example, we may disclose your protected health information to a laboratory to order pre-operative tests or to a pharmacy to fill a prescription. We may also disclose protected health information to physicians who may be treating you or consulting with the facility with respect to your care. In some cases, we may also disclose your protected health information to people outside the facility who may be involved in your medical care while you are in the facility or after you leave the facility, such as other physicians, health care workers, family members, clergy or others we use to provide services that are part of your care.
 
Payment
 
Your protected health information will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurance company to get approval for the treatment or care. For example, we may need to disclose information to your health insurance company to get prior approval for a surgery or inpatient stay. We may also disclose protected health information to your health insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for the services we provide to you, we may also need to disclose your protected health information to your health insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider’s payment activities. This may include disclosure of demographic information to anesthesia care providers for payment of their services.
 
Healthcare Operations
 
We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of the facility and to provide quality care to all patients. Health care operations include such activities as: quality assessment and improvement activities, employee review activities, training programs including those in which students, trainees, or practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services, maintaining compliance, business management, and general administrative activities.
 
In certain situations, we may also disclose patient information to another provider or health plan for their health care operations. Other uses and disclosures for health care operations may include:

v Care management

v Protocol Development

v Training, accreditation, certification, licensing, credentialing or other related activities

v Activities related to improving health care or reducing health care costs

v Underwriting and other insurance related activities

v Medical review and auditing

v Business planning and/or development

v Internal grievance resolution


Health Information Exchange

We may make your protected health information available electronically through an information exchange service to other health care providers, health plans and health care clearinghouses that request your information. Participation in information exchange services also lets us see their information about you.

Appointment Reminders

We may use or disclose your protected health information to contact you, a family member or friend involved in your health care as a reminder that you have an appointment for treatment or medical care at our facility. We may also leave a message on your answering machine / voicemail system. Please notify the Privacy Officer if you do not want us to leave messages with an individual who answers your phone or with your automated answering service, if applicable.

Business Associates

To a business associate with whom we contract to provide services on our behalf.

Department of Health and Human Services

To disclose medical information when required as part of an investigation or determination of compliance with laws.


Disaster Relief

Information may be communicated to an entity assisting in a disaster relief effort in order to communicate your condition status and location to your family. If you want any of this information restricted, you must notify the Privacy Officer in writing.

Treatment Alternatives/Health Related Benefits and Services

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

Fundraising Activities

We may use or disclose your protected health information to contact you in an effort to raise money for the facility and its operations. We may disclose health information to a foundation related to the facility so that the foundation may contact you in raising money for the facility. We would only release demographic information, such as your name, address, phone number and the dates you received treatment or services at the facility. If you do not want the facility to contact you for fundraising efforts, you must notify the Privacy Officer in writing.

Individuals Involved in Your Care/Payment

We may use or disclose your protected health information to a friend or family member who is involved in your medical care. We may also give information to someone assisting you in the payment for your care. We may also tell your family or friends that you are in the facility at the time of your care. If you want any of this information restricted, you must communicate this to us.

Research

Under certain circumstances, we may use and disclose 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 procedure to those who received another procedure for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with the patients’ need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, but we may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave the hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the Facility.

As Required By Law

We will disclose health information about you when required to do so by federal, state, or local law. This may include reporting of communicable diseases, wounds, abuse, neglect, exploitation, domestic violence, disease/trauma/birth/cancer registries, health oversight matters and other public policy requirements.


To Avert a Serious Threat to Health or Safety

We may use and disclose health information for the following public activities and purposes:
 
v To prevent, control, or report disease, injury or disability as permitted by law.

v To report vital events such as birth or death as permitted or required by law.

v To conduct public health surveillance, investigations and interventions as permitted or required by law.

v To collect or report adverse events and product defects, track FDA regulated products; enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.

v To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.

v To report to an employer information about an individual who is a member of the workforce as legally permitted or required.


To Conduct Health Oversight Activities.

We may disclose your protected health information to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law.

In Connection With Judicial And Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order. In certain circumstances, we may disclose your protected health information in response to a subpoena to the extent authorized by state law if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order.

For Law Enforcement Purposes.

We may disclose your protected health information to a law enforcement official for law enforcement purposes as follows:

v As required by law for reporting of certain types of wounds or other physical injuries including suspected foul play, child/adult abuse, stab wounds, auto accidents, injuries due to fighting, intentional poisonings, attempted suicide, assault, rape, and any accident that may lead to a court case.

v Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.

v For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.

v Under certain limited circumstances, when you are the victim of a crime.

v To a law enforcement official if the facility has a suspicion that your health condition was the result of criminal conduct.

v In an emergency to report a crime, reporting crimes on premises, and reporting deaths by suspected criminal conduct.


Inmates
 
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
 
To Coroners, Funeral Directors, and Organ Procurement Organizations
 
We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation for the purpose of facilitating organ, eye, or tissue donation and transplantation.
 
For Specified Government Functions
 
In certain circumstances, federal regulations authorize the facility to use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.
 
For Worker's Compensation
 
The facility may release your health information to comply with worker's compensation laws or similar programs. According to KRS 342.020, an employee who reports an alleged work-related injury for adjustment of a claim shall execute a waiver and consent of the physician-patient privilege with respect to any condition or complaint reasonably related to the condition for which the employee claims compensation. Twin Lakes Regional Medical Center shall provide the employee, employer, worker’s compensation insurer, special fund, uninsured employer’s fund, or the administrative law judge with any information or written material reasonably related to any injury or disease for which the employee claims compensation with documentation supporting the waiver and consent, or the Worker’s Compensation Application.
 
 
Uses and Disclosures which you Authorize
 
Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.
 
 
YOUR RIGHTS
 
Although your health record is the physical property of the facility that compiled it, the information contained within the record belongs to you. You have the following rights regarding your health information:
 
Right to Inspect and Obtain a Copy of your Protected Health Information
 
You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, your physician may deny access to inspect and /or copy your records.
 
We may deny your request to inspect or obtain copies of your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision in certain circumstances.
 
To obtain a copy of your medical information, you must complete the proper paperwork located in Health Information Services. According to Kentucky statute, you are entitled to obtain one free copy of your medical records and a charge of $1.00 per page will be charged for furnishing a second copy.
 
To inspect your medical information, contact the healthcare professional involved in your care or Health Information Services.
 
Right to Request Amendments to your Protected Health Information
 
If you feel the health information we have in your record is incorrect or incomplete, you may request an amendment of the information for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
 
In addition, we may deny your request if you ask us to amend information that:

v Was not created by this facility

v Was created by someone no longer available to make the amendment.

v Is not part of the health information kept by our facility; or

v Is accurate and complete.


Forms for requesting amendments are located in Health Information Services or you may contact the Privacy Officer.

Right to Request a Restriction on Uses and Disclosures of your Protected Health Information You may ask us to not use or disclose certain parts of your protected health information for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care, payment, disaster relief efforts, or for notification purposes as described in this Privacy Notice. We will notify you if we deny your request to a restriction. If the facility does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by completing a form located in Health Information Services or by contacting the Privacy Officer.


Right to Request Confidential Communications from us by Alternative Means or at an Alternative Location

You have the right to request that we communicate to you by alternative means or at an alternative location. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing and submitted to the Privacy Officer.

Right to Receive an Accounting of Disclosures of Protected Health Information.

You have the right to request an accounting of certain disclosures of your protected health information made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, to authorized federal officials, disclosures incidental to another permitted use/disclosure, or certain other disclosures we are permitted to make without your authorization. The request for an accounting may be made by completing a form located in Health Information Services or by contacting the Privacy Officer. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting during any 12-month period without charge. Subsequent accountings are $1.00 each.

Right to Obtain a Paper Copy of this Notice.

Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.

OUR RESPONSIBILITIES

The facility is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our legal duties and privacy practices.

We are required to:

v Keep your health information private;

v Explain our legal duties and privacy practices in connection with your health records;

v Obey the rules found in this notice;

v Inform you when we are unable to agree to a requested restriction that you have given us;

v Accommodate your reasonable request for an alternative means of delivery or destination when sending your health information.

We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the facility changes its Notice, we will post the new Notice at the facility, have copies available for distribution, and revise the Notice on our website.

COMPLAINTS
You have the right to express concerns or file a complaint with the facility and the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. You may voice concerns or file a complaint with the facility by contacting the facility’s Privacy Officer verbally or in writing. You will not be retaliated against for filing a complaint or voicing a concern. The facility’s contact person for all issues regarding patient privacy, access to health information, and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by this facility you may submit a complaint to our Privacy Officer by sending it to:
Twin Lakes Regional Medical Center
ATTN: Privacy Officer
910 Wallace Avenue
Leitchfield, KY 42759
270-259-9519
 
 
EFFECTIVE DATE: April 14, 2003.
Updated: 8/26/11