Notice of Privacy Practices

LISBON AREA HEALTH SERVICES
NOTICE OF PRIVACY PRACTICES

Effective Date: 4/2003; Revised 2(5/03)-3(2/05)-4(3/11)

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 the Privacy Official at 701-683-6400

Definitions

Notice of Privacy Practices (The Notice) – a written notice in compliance with the requirements of Health Insurance Portability and Accountability Act (HIPAA), made available from Lisbon Area Health Services to a patient or personal representative at the first delivery of service, or at the patient’s next visit following a revision to the Notice, that describes the uses and disclosures of protected health information that may be made by Lisbon Area Health Services and the patient’s rights and Lisbon Area Health Services legal duties with respect to protected health information.

Protected Health Information (PHI) – individually identifiable health information that is transmitted or maintained in any form or medium, including electronic media. Protected health information does not include employment records held by Lisbon Area Health Services in its role as an employer.

Lisbon Area Health Services, an affiliate member of Catholic Health Initiatives (CHI), and other affiliated members of CHI participate in an Organized Health Care Arrangement (OHCA) in order to share health information to manage joint operational activities. A complete list of CHI affiliated members is available at www.catholichealthinitiatives.org by clicking on “Where We Are”. A paper copy is available upon request. The CHI OHCA may use and disclose your health information to provide treatment, payment, or health care operations for the affiliated members such as integrated information system management, financial and billing services, insurance, quality improvement, and risk management activities.

Lisbon Area Health Services, including healthcare providers, participate in an OHCA to manage their joint operating activities similar to the CHI OHCA. The Lisbon Area Health Services OHCA may use and disclose your health information to provide treatment, payment, or health care operations to the OHCA members such as management services, integrated information system management, financial and billing services, insurance, quality improvement, and risk management activities.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

For Treatment. We will use your health information to provide you with health care treatment and to coordinate or manage services with other health care providers, including third parties. We may disclose all or any portion of your health information to your attending physician, consulting physician(s), nurses, technicians, health profession students, or other facility or health care personnel who have a legitimate need for such information in order to take care of you. Different departments of the facility will share your health information in order to coordinate the health care services you need, such as prescriptions, lab work and X-rays. We may disclose your health information to family members or friends, guardians or personal representatives who are involved with your medical care. We may also use and disclose your health information to contact you for appointment reminders and to provide you with information about possible treatment options or alternatives and other health-related benefits and services. We also may disclose your health information to people outside the facility who may be involved in your health care after you leave the facility, such as other physicians involved in your care, specialty hospitals, skilled nursing care facilities, and other healthcare-related services.

For Payment. We will use and disclose your health information for activities that are necessary to receive payment for our services, such as determining insurance coverage, billing, payment and collection, claims management, and medical data processing. For example, we may tell your health plan about a treatment you are planning in order to receive approval or to determine whether your plan will pay for the proposed treatment. We may disclose your health information to other health care providers so they can receive payment for health care services that they provided to you, such as your personal physician, and other physicians involved in your medical care such as an anesthesiologist, pathologist, radiologist, or emergency physician, and ambulance services. We may also give information to other third parties or individuals who are responsible for payment for your health care, such as the named insured under the health policy who will receive an explanation of benefits (EOB) for all beneficiaries who are covered under the insured’s plan.

For Health Care Operations. We may use and disclose your health information for routine facility operations, such as business planning and development, quality review of services provided, internal auditing, accreditation, certification, licensing or credentialing activities (including the licensing or credentialing activities of health care professionals), medical research and education for staff and students, assessing your satisfaction with our services, and to other healthcare entities that have a relationship with you and need the information for operational purposes. We may use and disclose your health information to the external agencies responsible for oversight of health care activities such as the The Joint Commission, external quality assurance and peer review organizations, and credentialing organizations. We may also disclose health information to business associates we have contracted with to perform services for or on our behalf such as patient satisfaction survey organizations. We may also disclose your health information to medical device manufacturers or pharmaceutical companies in order for those companies to carry out their legal obligations to state and federal agencies.

Facility Directory. The facility directory is available so that your family, friends, and clergy can visit you and generally know how you are doing. We may include your name, location in the facility, your general condition (for example, fair or stable, or even the death of a person), and your religious affiliation in the facility directory. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your name and religious affiliation may be given to a member of the clergy such as a priest or rabbi, even if they don’t ask for you by name. You must notify admissions personnel or the Privacy Official at 905 Main Street Lisbon ND 58054 or 701-683-6400 verbally or in writing if you do not want us to release information about you in the facility directory. If you do not want information released in the facility directory, we cannot tell members of the public such as flower or other delivery services or friends and family that you are here or about your general condition.

Future Communications. We may provide communications to you with newsletters or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our facility is participating.

Fundraising Activities. We may use your health information, or disclose your health information to a foundation related to us for Lisbon Area Health Service’s fundraising efforts. These funds would be used to expand and improve services and programs we provide to the community. We would only release information such as your name, address, phone number, and the dates that you received treatment or services from us. If you do not want us to contact you for fundraising efforts you must notify the HIPPA Privacy Officer at 905 Main Street Lisbon ND 58054 or 701-683-6400 verbally or in writing, stating that you do not want to receive the information.

Research. We may use and disclose your health information to researchers either when you authorize the use and disclosure of your health information, or the Lisbon Area Health Services Institutional Review Board and/or Privacy Board approves an authorization waiver for the use and disclosure of your health information for a research study.

Organ and Tissue Donation. If you are an organ donor, we may release your health information to organizations that handle organ procurement and transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

USES AND DISCLOSURES THAT ARE REQUIRED OR PERMITTED BY LAW

Subject to requirements of federal, state and local laws, we are either required or permitted to report your health information for various purposes. Some of these reporting requirements and permissions include:

Public Health Activities. We may disclose your health information to public health officials for activities related to the prevention or control of communicable disease, bioterrorism, injury or disability; to report births and deaths; to report suspected child, elder, or spouse abuse or neglect; to report reactions to medications or problems with medical products; to report information to the Centers for Disease Control or to authorized national or state cancer registries for their data aggregation.

Disaster Relief Efforts. We may disclose your health information to an entity assisting in a disaster relief effort, such as the American Red Cross, so that your family can be notified about your condition and location.

Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. Such agencies include federal Centers for Medicare and Medicaid Services, and state medical or nursing boards. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor activities such as health care treatment and spending, government programs, and compliance with civil rights laws.

Judicial or Administrative Proceeding. We may disclose your health information in response to a legal court or administrative order, a subpoena, discovery request, civil or criminal proceedings, or other lawful process.

Law Enforcement. We may release your health information if asked to do so by a law enforcement official or if we have a legal obligation to notify the appropriate law enforcement or other agencies:

• In response to a court order, subpoena, warrant, summons or similar legal process;

• Regarding a victim or death of a victim of a crime in limited circumstances;

• In emergency circumstances to report a crime, the location or victims of a crime, or the identity, description or location of a person who is alleged to have committed a crime, including crimes that may occur at our facility, such as theft, drug diversion, or attempts to obtain drugs illegally.

Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or a medical examiner. This may be necessary to identify a person who died or to determine the cause of death. We may release health information to help a funeral director to carry out his/her duties.

Workers' Compensation. We may release your health information for workers’ compensation benefits or similar programs that provide benefits for work-related injuries or illnesses if you tell us that workers’ compensation is the payer for your visit(s). Your employer or their workers’ compensation carrier may request the entire medical record pertinent to your workers’ compensation claim. This medical record may include details regarding your health history, current medications you are taking, and treatments.

To Avert a Serious Threat to Health or Safety. We may disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public.

National Security. We may disclose your health information to federal official(s) for national security activities and for the protection of the President and other Heads of State.

Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may release your health information to the institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us with authorization to use or disclose your health information, you may revoke that authorization in writing at any time. When we receive your written revocation we will no longer use or disclose your health information for the purpose of that authorization. However, we are unable to retrieve any disclosures already made based your prior authorization.

THIS NOTICE DOES NOT APPLY TO THE FOLLOWING NON-COVERED FUNCTIONS THAT DO NOT CONDUCT STANDARD ELECTRONIC TRANSACTION: THE HOSPITAL’S WELLNESS SERVICES (SUCH AS BUT NOT LIMITED TO HEALTH FAIRS, COMMUNITY CLASSES, CHOLESTEROL AND BLOOD PRESSURE SCREENINGS), SCHOOL SCREENINGS, PARISH NURSING AND COMMUNITY RESOURCE SERVICES.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding your health information:

Right to Inspect and Copy. You have the right to inspect your health information and receive a copy of medical, billing, or other records that may be used to make decisions about your care. The right to inspect and receive a copy may not apply to psychotherapy notes that are maintained separately from the health record.
Your request to inspect and receive a copy of your health information must be submitted in writing. We may charge a fee for document requests to cover the costs of copying, mailing, or other supplies.
In limited circumstances we may deny your request to inspect or receive a copy of your health information. If you are denied access to your health information, you may request that the denial be reviewed. A licensed health care professional chosen by Lisbon Area Health Services will review your request and the denial. The person who conducts the review will not be the same person who denied your request. We will comply with the outcome of the review.

Right to Amend. You have the right to request an amendment to your health information that you believe is incorrect or incomplete.

Submit your request in writing, including your reason for the amendment, using our “Request for Amendment to PHI” form and send to Health Information Management, Lisbon Area Health Services, 905 Main Street Lisbon ND 58054 or 701-683-6400.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that:

• Was not created by Lisbon Area Health Services 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 Lisbon Area Health Services;

• Is not part of the information that you would be permitted to inspect and copy; or

• Is accurate and complete.

Right to an Accounting of Disclosures. We are required to maintain a list of disclosures of your health information. However, we are not required to maintain a list of disclosures that we made by acting upon your written authorizations. You have the right to request an accounting of disclosures that are not subject to your written authorization.

Submit your request in writing using our “Request for Accounting of Disclosures of PHI” form and send to Health Information Management, Lisbon Area Health Services, 905 Main Street Lisbon ND 58054 or 701-683-6400. Your request must state a time period, not longer than six years from the date of request. Your request will be provided in paper form. 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 before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on how much of your health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a restriction on the disclosure of your health information to someone who is involved in your care or payment for your care, such as a family member or friend.

We are not required to agree to your request. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Submit your request in writing or request and submit a “Request for Restrictions to Use or Disclose Protected Health Information” form and send to Health Information Management, Lisbon Area Health Services, 905 Main Street Lisbon ND 58054 or 701-683-6400. You must include: a description of the information that you want to restrict, whether you want to restrict our use or disclosure or both; and to whom you want the restriction to apply.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at an alternative location from your home address, such as work, or only contact you by mail instead of by phone. Your request must specify how or where you wish to be contacted. We do not require a reason for the request. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. If you have agreed to receive this notice electronically, you are still entitled 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 Admissions Personnel, Lisbon Area Health Services, 905 Main Street Lisbon ND 58054 or 701-683-6400.

Or, you may obtain a copy of this notice at our Web site: www.lisbonhospital.com.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you and for any information we may receive in the future. We will post a copy of the current notice in the facility and on our web site (if applicable) at Lisbon Area Health Services. The notice will contain the effective date. Upon your initial registration or admittance to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the notice currently in effect. Whenever the notice is revised, it will be available to you upon request.

COMPLAINTS

You may file a complaint with us or with the Secretary of the Department of Health and Human Services if you believe that we have not complied with our privacy practices.

You may file a complaint with us by contacting the Privacy Official, Lisbon Area Health Services, 905 Main Street Lisbon ND 58054 or 701-683-6400.

If you file a complaint, we will not take any action against you or change our treatment of you in any way.