Powell
County Memorial Hospital - Powell County Clinic
Powell County Medical Center
1101 Texas
Avenue Deer Lodge, MT 59722 Hospital (406) 846-2212 Clinic (406 846-1722 Fax (406) 846-3074
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.
If you have any questions about this Notice please contact our
Administrator.
Our Pledge Regarding Medical Information
We understand that medical
information about you and your health is personal. We are committed to
protecting medical information about you. We create a record of the care and
services you receive at the hospital. We need this record to provide you with
quality care and to comply with certain legal requirements. This notice applies
to all of the records of your care generated by the hospital, whether made by
hospital personnel or your personal doctor.
This Notice of Privacy Practices describes
how we may use and disclose your protected health information to carry out
treatment, payment or health care operations and for other purposes that are
permitted or required by law. It also describes your rights to access and
control your protected health information. “Protected health information” is
information about you, including demographic information, that may identify you
and that relates to your past, present or future physical or mental health or condition
and related health care services.
We are required to abide by the terms of
this Notice of Privacy Practices. We may change the terms of our notice, at any
time. The new notice will be effective for all protected health information
that we maintain at that time. We will post a copy of the current notice in the hospital. The notice
will contain on the first page, in the top right-hand corner, the effective
date. Upon your request, we will provide you with
any revised Notice of Privacy Practices by accessing our website www.pcmh.org,
calling the office and requesting that a revised copy be sent to you in the
mail or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health
Information
Uses and Disclosures of Protected Health
Information Based Upon Your Written Consent
You will be asked by admissions personnel
to sign a consent form. Once you have consented to use and disclosure of your
protected health information for treatment, payment and health care operations
by signing the consent form, Powell County Medical Center will use or disclose
your protected health information as described in this Section 1. Your
protected health information may be used and disclosed by your physician, our
office staff and others outside of our office that are involved in your care
and treatment for the purpose of providing health care services to you. Your
protected health information may also be used and disclosed to pay your health
care bills and to support the operation of the facility’s practice.
Following are examples of the types of uses
and disclosures of your protected health care information that the facility is
permitted to make once you have signed our consent form. These examples are not
meant to be exhaustive, but to describe the types of uses and disclosures that
may be made by our office once you have provided consent.
Treatment: We will 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 a third party that has already obtained your permission to have
access to your protected health information.
For
example, a doctor treating you for a broken leg may need to know if you have
diabetes because diabetes may slow the healing process. In addition, the doctor
may need to tell the dietitian if you have diabetes so that we can arrange for
appropriate meals. Different departments of the hospital also may share medical
information about you in order to coordinate the different things you need,
such as prescriptions, lab work and x-rays. We also may disclose medical
information about you to people outside the hospital who may be involved in
your medical care after you leave the hospital, such as skilled nursing
facilities or home health agencies. For example, your
protected health information may be provided to a physician to whom you have
been referred to ensure that the physician has the necessary information to
diagnose or treat you.
In addition, we may disclose your protected
health information from time-to-time to another physician or health care
provider (e.g., a specialist or laboratory) who, at the request of your
physician, becomes involved in your care by providing assistance with your
health care diagnosis or treatment to your physician.
Payment: Your protected health information will be
used, as needed, to obtain payment for your health care services. This may
include certain activities that your health insurance plan may undertake before
it approves or pays for the health care services we recommend for you such as;
making a determination of eligibility or coverage for insurance benefits,
reviewing services provided to you for medical necessity, and undertaking
utilization review activities. For
example, obtaining approval for a hospital stay may require that your relevant
protected health information be disclosed to the health plan to obtain approval
for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your
protected health information in order to support the business activities of
Powell County Medical Center. These activities include, but are not limited to,
quality assessment activities, employee review activities, training of medical students,
licensing, marketing and fundraising activities, and conducting or arranging
for other business activities.
For example, we may disclose your protected
health information to medical school students that see patients at our office.
We may call you by name in the waiting room when your physician is ready to see
you. We may use or disclose your protected health information, as necessary, to
contact you to remind you of your appointment.
We will share your protected health
information with third party “business associates” that perform various
activities (e.g., billing, transcription services) for the practice. Whenever
an arrangement between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written
contract that contains terms that will protect the privacy of your protected
health information.
We may use or disclose your protected
health information, as necessary, to provide you with information about
treatment alternatives or other health-related benefits and services that may
be of interest to you. We may also use and disclose your protected health
information for other marketing activities. For example, your name and address
may be used to send you a newsletter about our practice and the services we
offer. We may also send you information about products or services that we
believe may be beneficial to you. You may contact our Administrator to request
that these materials not be sent to you.
We may use demographic information about you to contact you in an effort to raise money for the hospital and its operations. We may disclose demographic information to a foundation related to the hospital so that the foundation may contact you in raising money for the hospital. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify the hospital administrator in writing.
Uses and Disclosures of Protected Health
Information Based upon Your Written Authorization
Other uses and disclosures of your
protected health information will be made only with your written authorization,
unless otherwise permitted or required by law as described below. You may
revoke this authorization, at any time, in writing, except to the extent that
your physician or the physician’s practice has taken an action in reliance on
the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and
Disclosures That May Be Made With Your Consent, Authorization or Opportunity to
Object
We may use and disclose your protected
health information in the following instances. You have the opportunity to
agree or object to the use or disclosure of all or part of your protected
health information. If you are not present or able to agree or object to the
use or disclosure of the protected health information, then your physician may,
using professional judgment, determine whether the disclosure is in your best
interest. In this case, only the protected health information that is relevant
to your health care will be disclosed.
Facility Directories: Unless you object, we may use and disclose
in a facility directory your name, the location at which you are receiving
care, your condition (in general terms), and your religious affiliation. All of
this information, except religious affiliation, will be disclosed to people
that ask for you by name. Members of the clergy will be told your religious
affiliation.
Others Involved in Your Healthcare: Unless you object, we may disclose to a
member of your family, a relative, a close friend or any other person you
identify, your protected health information that directly relates to that
person’s involvement in your health care. If you are unable to agree or object
to such a disclosure, we may disclose such information as necessary if we
determine that it is in your best interest based on our professional judgment.
We may use or disclose protected health information to notify or assist in
notifying a family member, personal representative or any other person that is
responsible for your care of your location, general condition or death.
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.
Emergencies: We may use or disclose your protected
health information in an emergency treatment situation. If this happens, your
physician shall try to obtain your consent as soon as reasonably practicable
after the delivery of treatment. If your physician or another physician in the
practice is required by law to treat you and the physician has attempted to
obtain your consent but is unable to obtain your consent, he or she may still
use or disclose your protected health information to treat you.
Communication Barriers: We may use and disclose your protected
health information if your physician or another physician in the practice
attempts to obtain consent from you but is unable to do so due to substantial
communication barriers and the physician determines, using professional
judgment, that you intend to consent to use or disclosure under the
circumstances.
Other Permitted and Required Uses and
Disclosures That May Be Made Without Your Consent, Authorization or Opportunity
to Object
We may use or disclose your protected
health information in the following situations without your consent or
authorization. These situations include:
Required By Law: We may use or disclose your protected
health information to the extent that the use or disclosure is required by law.
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, as
required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health
information for public health activities and purposes to a public health authority
that is permitted by law to collect or receive the information. The disclosure
will be made for the purpose of controlling disease, injury or disability. We
may also disclose your protected health information, if directed by the public
health authority, to a foreign government agency that is collaborating with the
public health authority.
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.
Health Oversight: We may disclose protected health
information to a health oversight agency for activities authorized by law, such
as audits, investigations, and inspections. Oversight agencies seeking this
information include government agencies that oversee the health care system,
government benefit programs, other government regulatory programs and civil
rights laws.
Abuse or Neglect: We may disclose your protected health
information to a public health authority that is authorized by law to receive
reports of child abuse or neglect. 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 the governmental entity or agency authorized to receive
such information. In this case, the disclosure will be made consistent with the
requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health
information to a person or company required by the Food and Drug Administration
to report adverse events, product defects or problems, biologic product
deviations, track products; to enable product recalls; to make repairs or
replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health
information in the course of any judicial or administrative proceeding, in
response to an order of a court or administrative tribunal (to the extent such
disclosure is expressly authorized), in certain conditions in response to a
subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health
information, so long as applicable legal requirements are met, for law enforcement
purposes. These law enforcement purposes include (1) legal processes and
otherwise required by law, (2) limited information requests for identification
and location purposes, (3) pertaining to victims of a crime, (4) suspicion that
death has occurred as a result of criminal conduct, (5) in the event that a
crime occurs on the premises of the practice, and (6) medical emergency (not on
the Practice’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ
Donation: We may
disclose protected health information to a coroner or medical examiner for
identification purposes, determining 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 purposes.
Research: We may disclose your protected health
information to researchers when their research has been approved by an
institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your protected health
information.
Criminal Activity: Consistent with applicable federal and
state laws, we may disclose your protected health information, if we believe
that the use or disclosure is necessary to prevent or lessen a serious and
imminent threat to the health or safety of a person or the public. We may also
disclose protected health information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we
may use or disclose protected health information of individuals who are Armed
Forces personnel (1) for activities deemed necessary by appropriate military
command authorities; (2) for the purpose of a determination by the Department
of Veterans Affairs of your eligibility for benefits, or (3) to foreign
military authority if you are a member of that foreign military services. We
may also disclose your protected health information to authorized federal officials
for conducting national security and intelligence activities, including for the
provision of protective services to the President or others legally authorized.
Workers’ Compensation: Your protected health information may be
disclosed by us as authorized to comply with workers’ compensation laws and
other similar legally-established programs.
Inmates: If you are an inmate of a
correctional institution or under the custody of a law enforcement official, we
may release medical 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.
Required Uses and Disclosures: Under the law, we must make disclosures to
you and when required by the Secretary of the Department of Health and Human
Services to investigate or determine our compliance with the requirements of
Section 164.500 et. seq.
2. Your Rights
Following is a statement of your rights
with respect to your protected health information and a brief description of
how you may exercise these rights.
You have the right to inspect and copy your
protected health information. This means you may inspect and obtain a copy of protected health
information about you 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 and any other records that your physician
and the practice use for making decisions about you.
Under federal law, however,
you may not inspect or copy the following records; psychotherapy notes;
information compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, and protected health information that is
subject to law that prohibits access to protected health information. Depending
on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may
have a right to have this decision reviewed. Please contact our Administrator
if you have questions about access to your medical record.
You have the right to request a restriction
of your protected health information. This means you may ask us not to use or disclose any part
of your protected health information for the purposes of treatment, payment or
healthcare operations. You may also request that any part of your protected
health information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this Notice
of Privacy Practices. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
Powell County Medical Center is not
required to agree to a restriction that you may request. If the facility
believes it is in your best interest to permit use and disclosure of your
protected health information, your protected health information will not be restricted.
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. With this in mind, please
discuss any restriction you wish to request with your physician. To request restrictions, you
must make your request in writing to the facility administrator. 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, for example,
disclosures to your spouse.
You have the right to request to receive
confidential communications from us by alternative means or at an alternative
location. For example, you can ask that we only contact you at
work or by mail. We will
accommodate reasonable requests. We may also 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 request an
explanation from you as to the basis for the request. Please make this request
in writing to our Administrator.
You may have the right to have your
physician amend your protected health information. This means you may request an amendment of
protected health information about you in a designated record set for as long
as we maintain this information. In certain cases, we may deny your request for
an amendment. 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 us to amend
information that:
• Was not created by us, unless the person
or entity that created the information is no longer available to make the
amendment;
• Is not part of the medical information
kept by or for the hospital;
• Is not part of the information which you
would be permitted to inspect and copy; or
• Is accurate and complete.
Even if we deny your request
for amendment, you have the right to submit a written addendum, not to exceed
250 words, with respect to any item or statement in your record you believe is
incomplete or incorrect. If you clearly indicate in writing that you want the
addendum to be made part of your medical record we will attach it to your
records and include it whenever we make a disclosure of the item or statement
you believe to be incomplete or incorrect.
You have the right to receive an accounting
of certain disclosures we have made, if any, of your protected health
information. This
right applies to disclosures for purposes other than treatment, payment or
healthcare operations as described in this Notice of Privacy Practices. It
excludes disclosures we may have made to you, for a facility directory, to
family members or friends involved in your care, or for notification purposes.
The right to receive this information is subject to certain exceptions,
restrictions and limitations. To request this list or
accounting of disclosures, you must submit your request in writing to the
facility administrator. Your request
must state a time period which may not be longer than six years and may not
include dates before April 14, 2003. You may request a shorter timeframe. Your request should indicate in what form you want the list (for
example, on paper, electronically). The first list you request within a
12-month period will be free. For additional lists, 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.
You have the right to obtain a paper copy
of this notice from us,
upon request, even if you have agreed to accept this notice electronically.
3. Complaints
You may complain to us or to the Secretary
of Health and Human Services if you believe your privacy rights have been
violated by us. You may file a complaint with us by notifying our Administrator
of your complaint. We will not retaliate against you for filing a complaint.
You may contact our facility administrator at (406) 846-2212 or tlpfaff@pcmh.org for
further information about the complaint process. You may also view this notice online at www.pcmh.org under the Programs & Services
heading.
This notice was published and becomes
effective on February 15, 2003.