APPALACHIAN COMMUNITY HEALTH CENTER, INC.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
WHO WILL FOLLOW THIS NOTICE?
This Notice describes the practices of Appalachian Community Health Center, Inc. ("ACHC") and the practices that will be followed by all ACHC professionals and employees who handle your health information.
OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION
ACHC understands that health information about you and your health is personal. We are committed to protecting health information about you. We maintain our records and conduct our treatment environment with a goal of providing the highest level of protection for your health information, while still providing you with the highest level of care. This Notice applies to all of the records of your care which are received or created by ACHC.
Your other health treatment providers (e.g., doctors, psychiatrists, psychologists, hospitals, and all other providers) may have different policies or notices regarding the use and disclosure of your health information.
This Notice will tell you generally about the ways in which ACHC may use and disclose health information about you, but does not include all specific examples of uses and disclosures of health information. If you have any questions about uses and disclosures of your health information, you may contact the privacy official of ACHC designated below. Your health information, also referred to as protected health information, is that information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health information and related health care services. In this Notice, we also describe your rights and certain obligations ACHC has regarding the use and disclosure of protected health information. We are required by law to:
* make sure that health and other information that identifies you (protected health information) is kept private;
* give you this Notice of our legal duties and privacy practices with respect to protected health information about you that explains how, when and why we may use or disclose protected health information; and
* comply with the Notice that is currently in effect.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
By becoming a client of ACHC, you are giving consent for ACHC to use your protected health information for certain activities, including treatment, payment and other health care operations.
First of all, we may use and disclose protected health information about you so that ACHC and its professionals and employees can treat you. For example, we may obtain information from other providers about you so that we can be fully aware of your health history. We may also provide protected health information about you to other providers who may assist us with, or consult with us about, your treatment. For example, we may need to disclose information to a case manager who is responsible for coordinating your care. We may also disclose your health information to our clinicians and staff who are directly involved in your care. We may also share protected health information among members of your interdisciplinary treatment team, including treatment team members that are representatives of governmental agencies, representatives of other providers involved in your treatment, and other team members, representatives or advocates on the treatment team who are not health care professionals.
We may also use and disclose protected health information about you so that we may be paid for the health treatment we provide you. For example, we may provide information about your health treatment to your health insurance company, including but not limited to Medicaid, Medicare, whether government or private, or other payors or administrative service organizations, so that we can receive payment for the treatment we have provide you or comply with the policies of the health insurance company or other payor. These uses and disclosures include determinations of eligibility, reviews as to medical necessity of services, reviews as to whether services are authorized or certified, and utilization reviews to determine appropriateness of services.
3. Health care operations
We may also use and disclose protected health information about you for ACHC health care operations, in other words, those other tasks that we need to perform to deliver the highest quality of health services to you. For example, we may use information about your health treatment to evaluate the quality of health care rendered to you by our professionals and staff. We may use or disclose your protected health information for purposes of obtaining and maintaining any licensure, certification, accreditation, and qualifications, for conducting utilization review and for responding to audits.
4. Specific uses and disclosures
The following uses and disclosures of your protected health information may be made without any additional authorization from you. (Not every use or disclosure is listed, but be assured that all uses and disclosures made by ACHC are only those which are permitted under the law):
USES AND DISCLOSURES FOR APPOINTMENT REMINDERS
We may use and disclose your protected health information to contact you or leave a message for you as a reminder that you have an appointment at the office. However, we will do so consistent with your directions as to who we may contact and the manner in which the contact will be made regarding such reminders. You must advise us in writing as to your specific directions regarding disclosure of protected health information concerning reminders, and any changes to such directions. We will accommodate all reasonable requests.
USES AND DISCLOSURES TO OTHERS INVOLVED IN YOUR HEALTH CARE
We will honor your directions as to contacts with your family, a relative, a close friend, or any other person you identify, regarding your protected health information. You must advise us in writing as to your specific directions regarding disclosure of protected health information about your care, and any changes to your directions. We will not disclose any information related to your protected health information to others unless you specifically authorize us to disclose this information in writing. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
USES AND DISCOLOSURES OF MENTAL HEALTH RECORDS
Your mental health records will be released only upon your specific written consent and authorization, or the specific written consent and authorization of your legal guardian. Information regarding mental health patients will remain confidential; such information may be released to third parties only under certain specific and limited circumstances, such as: involuntary commitment proceedings, criminal competency proceedings, when court-ordered, in emergency situations to protect the patient, and for treatment by other providers or internal review. For patients receiving psychiatric or psychological treatment, your provider is only required to give you a summary of the records following termination of your treatment program, and access to these records may be limited during your treatment. Access to records that are considered psychotherapy notes may also be limited. If you have any questions regarding these limitations, you may direct your inquiries to the Privacy Official for ACHC designated below.
USES AND DISCLOSURES OF ALCOHOL AND OTHER DRUG RECORDS
The law provides that we may use/disclose your Protected Health Information from alcohol and other drug records without consent or authorization in the following circumstances. We may disclose Protected Health Information when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the program premises or against program personnel, or in response to a court order. We may also disclose Protected Health Information relating to an individual’s death is state or federal law required the information for collection of vital statistics or injury into cause of death. In certain circumstances, we may disclose Protected Health Information for research, audit or evaluation purposes. In order to avoid a serious threat to health or safety, we may disclose Protected Health Information to law enforcement when a threat is made to commit a crime on the program premises or against program personnel.
USES AND DISCLOSURES RELATED TO MINORS
Health records for minors will normally be release to custodial parents or parents that are otherwise authorized to obtain access to this information, legal guardians, and other legal representatives. There are certain circumstances in which disclosure of the health records of minors to parents is prohibited by law, such as certain records related to prenatal care and birth control, alcohol and substance abuse services, treatment of venereal disease, and other exceptions recognized by law. ACHC will abide by these prohibitions when we are required to do so. In addition, if ACHC determines that a minor is sufficiently mature to independently make decisions regarding health care, ACHC may also require the authorization of such a mature minor to release such records.
USES AND DISCLOSURES IN EMERGENCY SITUATIONS
We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician will attempt to obtain your acknowledgment of this Notice as soon as reasonably practicable after the delivery of treatment.
USES AND DISCLOSURES FOR HEALTH-RELATED BENEFITS OR SERVICES
From time to time, ACHC may use and disclose protected health information to tell you about certain health-related benefits or services that may be of interest to you.
USES AND DISCLOSURES RELATED TO FUNDRAISING ACTIVITIES
ACHC will not use or disclose your protected health information in fundraising activities unless you authorize ACHC in writing to do so. ACHC may use or disclose general information about your health care services that does not include personally identifiable information about you in its fundraising efforts without further authorization from you.
USES AND DISCLOSURES REQUIRED BY LAW
We will use or disclose protected health information about you when required to do so by federal, state, or local law, including reports of suspected abuse, neglect, domestic violence, and/or criminal activity. We may also use or disclose protected health information when required to so by a court order. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if the law requires us to do so, of any such uses or disclosures. We must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the law.
USES AND DISCLOSURES FOR PUBLIC HEALTH ACTIVITIES
We may disclose your protected health information for public health activities and disclosure for such purposes will be to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for purposes such as controlling disease, injury or disability. Disclosures to public health authorities may include disclosure to a foreign authority that is working with the public health authority.
USES AND DISCLOSURES RELATED TO COMMUNICABLE DISEASES
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Disclosure of AIDs-related testing information and related health records is limited to specific involuntary circumstances absent a specific AIDS-related records consent. All information regarding such a test will remain confidential, except for specific exceptions in which the law allows or requires uses or disclosures, unless authorized by you.
DISCLOSURES FOR HEALTH OVERSIGHT ACTIVITIES
We may disclose protected health information to protection and advocacy groups, quality control and utilization review committees, governmental agencies, and health oversight agencies for activities authorized by law. These activities include, for example, reviews, audits, investigations, and inspections. These activities are necessary to monitor the health care system, the delivery of health care, government benefit programs, other government regulatory programs, civil rights laws and compliance with applicable federal and state laws.
DISCLOSURES OF ABUSE OR NEGLECT
We may disclose your protected health information to a public health authority authorized by law to receive reports of abuse or neglect to children or to adults. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to a governmental entity or agency authorized to receive such information. In such cases, the disclosure will only be made in accordance with West Virginia law.
DISCLOSURES TO THE FOOD AND DRUG ADMINISTRATION
We may disclose your protected health information to a person or company required by the Food and Drug Administration (FDA) to report adverse events, product defects or other problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements; or to conduct post-market surveillance, as required.
DISCLOSURES FOR LAWSUITS AND DISPUTES, TO AVERT THREATS TO HEALTH AND SAFETY OR TO LAW ENFORCEMENT
We may disclose protected health information about you in response to a court order or administrative order. We may be required to disclose protected health information about you in response to a subpoena, discovery request, or other lawful process. We may disclose your protected health information, consistent with federal and West Virginia laws, if we believe that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public, or if it is necessary for law enforcement authorities to identify or apprehend an individual. We may also release protected health information if asked to do so by a law enforcement official, as required by federal and state law, in response to a court order, subpoena, warrant, summons, or similar process. We will first make reasonable efforts to tell you about the request at the most recent address you have provided to ACHC so that you can take any actions you feel are appropriate to protect your interests. In addition, if we are prohibited by law from disclosing protected health information regarding mental health records, alcohol and substance abuse records and/or AIDS related records without first obtaining your written authorization or a court order as required by federal and state laws, we will take reasonable steps to comply with these restrictions, and will disclose this information only if you authorize us or we are compelled by law to do so. Other related disclosures may include disclosures relating to individuals who are Armed Forces personnel, to national security and intelligence agencies, as well as disclosures to authorized federal officials for the protection of the President of the United States or other authorized persons or foreign heads of state.
DISCLOSURES TO CORONERS, FUNERAL DIRECTORS, AND FOR ORGAN DONATION
We may disclose protected health information about you to a coroner or medical examiner for identification purposes, determining cause of death, or for the coroner or medical examiner to perform other duties required by law. We may also disclose protected health information about you to a funeral director in order to permit the funeral director to carry out legal duties, and may do so if death is reasonably anticipated. Your protected health information may also be disclosed for certain organ donations to which you may have agreed.
DISCLOSURES FOR RESEARCH
We may disclose your protected health information to researchers when their research has been approved and protocols have been established to ensure the privacy of your information. We may also disclose a limited portion of your information, as allowed under the law, for research purposes.
DISCLOSURES FOR WORKERS’ COMPENSATION
We may release protected health information about you for workers’ compensation, social security disability, federal black lung and similar programs. These programs provide benefits for work-related injuries or illness.
IF YOU DO NOT AGREE WITH ANY OF THE USES OF PROTECTED HEALTH INFORMATION, YOU MUST REQUEST A SPECIFIC LIMITATION ON THE ABOVE USES IN WRITING TO OUR OFFICE.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to make decisions about your health care. Usually this right includes both health and billing records. You must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. Your request to inspect and copy your information may be denied under certain circumstances and you have a right to request that any such denial be reviewed.
Right to Request Restrictions. You have the right to request that we restrict the use and disclosure of your protected health information for treatment, payment and health care operations. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment unless there is an exception requiring such use or disclosure. To request restrictions, you must make your request in writing to the Privacy Official of ACHC. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.
Right to Confidential Communications. You also have the right to request to receive private health information communications (such as test results, appointment reminders, etc.) by alternative means or at alternative locations. 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 to the Privacy Official of ACHC. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Amend. If you feel that the protected health information we have about you is incorrect or incomplete, you have the right to request that your protected health information be amended. Only the health care entity (e.g., doctor, hospital, clinic, etc.) that created your protected health information is responsible for amending it. For more information regarding the procedures for submitting such a request, contact the Privacy Official of ACHC.
Right to an Accounting of Disclosures. You have a right to an accounting of disclosures of your protected health information, for purposes other than treatment, payment or health care operations by ACHC or any of the people or companies who perform treatment, payment or health care operations on our behalf. To request this list of disclosures we made of protected health information about you, you must submit a request in writing to the Privacy Official of ACHC. Your request must state a time period, which may not be longer than six (6) years prior to the date of your request and may not include dates before April 16, 2003. Your request should indicate the form in which you want the list (for example, on paper or electronically). ACHC may charge a reasonable fee to you for providing this information to you according to its current policies.
Right to a Paper Copy of this Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this Notice, contact the Privacy Official of ACHC at the address or telephone number specified below.
CHANGES TO THIS NOTICE
ACHC reserves the right to change this notice at any time. 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 create or receive in the future. The Notice will contain, in the bottom, left-hand corner, the effective date. If we do so, we will post a new notice at all clinic sites and you may request a copy at the registration desk at any clinic site. In addition, you may obtain a copy from the privacy official designated above.
OTHER USES OF PROTECTED HEALTH INFORMATION
This Notice describes the limited rights of ACHC to use and disclose your protected health information. Other uses and disclosures of your protected health information not covered by this notice or the laws that apply to ACHC will be made only with your written permission ("authorization"). If we disclose protected health information to an outside entity, we will take reasonable steps to assure the outside entity protects the confidentiality of your protected health information, including, if necessary, agreements with the outside entity intended to protect your privacy. If you provide us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the health treatment or other services that we have provided to you for a limited period of time.
COMPLAINTS AND INQUIRIES
If you believe your privacy rights have been violated and/or that ACHC has not followed this policy, you may file a complaint with ACHC's Privacy Official or with the Secretary of the Department of Health and Human Services. To file a complaint with ACHC, contact the Privacy Official of ACHC at the below address and telephone number. You will not be penalized for filing a complaint. If you have questions about this Notice or about filing a complaint, you may contact the Privacy Official designated below.
PRIVACY OFFICICAL OF ACHC - Phyllis Mace, Chief Privacy Officer
Appalachian Community Health Center, Inc.
725 Yokum Street
Elkins, West Virginia 26241
Telephone number: (304) 636-3232
EFFECTIVE DATE: 04/14/2003
APPALACHIAN COMMUNITY HEALTH CENTER, INC.
PATIENT ACKNOWLEDGMENT FORM
Our Notice of Privacy Practices (Notice) provides information about how we may use and disclose protected health information about you. You have the right to receive and review our Notice before signing this acknowledgment. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy.
By signing this form, you acknowledge that you have been informed of our uses and disclosures of protected health information about you for all of the purposes set out in our Notice.
By signing this form, you also acknowledge that a copy of our Notice has been provided to you, that you understand the contents of our Notice and how it applies to you, and that all of your questions regarding the contents of our Notice have been answered.
EFFECTIVE DATE: 04/14/2003