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PIONEERS HOSPITAL
NOTICE OF PRIVACY PRACTICES CONSENT
(Note: All references to Pioneers Hospital shall encompass Pioneers Hospital, Walbridge
Wing, Meeker Family Health Center and Pioneers Hospital Home Health.)
Download a PDF copy of this form.
1. Uses and disclosures of your personal health information that does not require an authorization signed by you.
a. Treatment
(i) We may use or disclose your personal health information to health care providers and their support staff so that we can properly manage your care and make then best decisions for treatment options. Your personal health information may be shared with other healthcare facilities in which case we transfer your care, refer your care to other healthcare providers or to other requesting healthcare organizations that are currently providing you with treatment.
b. Payment and Billing Activities
We may use your personal health information as it relates to payment for your healthcare treatment, such as sharing your information with our business office, our clearinghouse, any contracted workforce member and your insurance carrier responsible for payment of your bill. At times it may be necessary to send copies of your medical record to your insurance carrier in order to expedite payment.
c. Other Healthcare Operations
We may use or disclose your personal health information for quality assurance purposes, utilization review, support service operations, and other operational activities that necessitate the use of disclosure of your personal health information. Pioneers Hospital restricts the mount of information used for these activities by allowing the minimum necessary to be used or disclosed in order to carry our the operational task.
2. Uses and Disclosures That Require Your 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. You may revoke an authorization at any time as described below, under Your Rights.
3. Other Uses and Disclosures
a. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
b. We may use or disclose your information as required by state and federal law.
c. We may disclose your information for public health activities such as investigations related to death, child abuse, neglect, domestic violence,
problems with products, reactions to medications, product recalls, disease/infection exposure, and disease/injury/disability control/prevention.
d. We may disclose identification data for health oversight activities such as audits, investigations, and inspections by state or federal organizations.
e. We may use or disclose your information pursuant to judicial and administrative proceedings.
f. We may disclose identification data as appropriate to law enforcement requests, for example to identify or locate a suspect, fugitive, material
witness, or missing person.
g. We may disclose your personal health information when deceased to coroners, medical examiners, and funeral directors.
h. Specific to organ and tissue donation.
i. For research, provided authorization is IRB-approved or privacy boardapproved.
j. During emergencies or to avert serious threat to health or safety.
k. For specialized government functions (military, inmates).
l. For worker’s compensation.
4. You have the right to agree or object to the following uses and disclosures:
(Please initial next to those uses and disclosures you object to, if you agree leave blank.)
• Facility Directory: Unless you object, we will use the following information in our facility directory: your name, location in which your are receiving care, your condition in general terms and your religious affiliation. We will disclose this information to anyone who asks for you by your complete and legal name with the exception of your religious affiliation. Only clergy members will receive you religious affiliation.
If you object to this initial here:______________
• Others Involved in Your Healthcare: Unless you object, we may disclose your personal health information to your family, significant other, relative or close friend for notification purposes, disaster relief efforts, or as it relates to their direct involvement of your treatment.
If you object to this initial here:_______________
• Fundraising Activities: We may also contact you to help us in our fundraising activities.
If you object to this initial here:_______________
5. Your Rights
a. You have a right to access or obtain copies of your medical record.
You may submit a written request to our Health Information Management Department and pay the copy fee and receive a copy of your medical record. We must respond to you within 30 days if the record is available at the time of the request and may respond to you within 60 days if it not readily available.
b. You have a fight to request confidential communications.
All communications in our organization are confidential however you may request confidential communications by directing your request to the Health Information
Management Department.
c. You have a right to request an amendment or correction to your medical record. If you believe that come of your medical information is inaccurate you may request in writing a request to amend your medical record. We have forms available to you for this purpose. Please feel free to call or write to request a form. Please direct completed form to the Privacy Officer. We must respond to you within 60 days.
d. You have a right to restrict the further use or disclosure of your personal health information. This request limited to those requests that do not interfere with treatment, payment and other healthcare operations. If our organization believes it can accommodate your request we will do so.
e. You have the right to receive an accounting of your disclosures of protected health information.
If you would like an accounting of your disclosures for the past six years, beginning April 14, 2003 you may request one in writing and direct the request to our Health Information Management Department. We must respond within 60days.
f. You have the right to revoke an authorization.
You have the right to revoke an authorization that you may have signed however no longer wish for it to be active. We will recognize your request on the date that we receive your revocation, however we are not responsible for any uses or disclosures acted on behalf of the authorization prior to the date of your revocation.
6. Complaints
Please understand that we believe your personal health information is private and should be respected at all times. If you believe that you information has not been treated this way please contact our Privacy Officer or his or her designee either by telephone or mail with the following information so your situation can be
addressed and or investigated:
- Complete Name
- Telephone number and best time we can reach you.
- Date of occurrence and your account number if known
- Names of people you believed we responsible
- A detailed description of your complaint
If you do not want to contact our facility you may contact the Secretary of the Department of Health and Human Services. Pioneers Hospital will not retaliate against you for filing a complaint.
7. Contact Information
You may contact our Privacy Officer or his or her designee at (970) 878-5047 if you have any questions or concerns related to this notice or if you ;wish to report a privacy violation.
8. Effective Date:
The notice went into effect on March 3, 2003.
9. Joint Notice.
This notice cover more than one health care organization. Other healthcare organizations may use or disclose your personal health information, as necessary to carry out treatment, payment , or health care operations relating to the organized health care arrangement. The other organizations that may use or disclose your information according to this notice include:
10. Signatures
By signing this document, I am acknowledging that I have received this document. I also understand that it is my responsibility to review the document and seek for clarification if I do not understand some or all of the content in this notice.
_______________________________________________ __________________________________
Print Patient’s Full Legal Name Date of Birth
___________________________________________________________________________
Acknowledging Signature Relationship to Patient Date
_______________________________________________________________________
Witness Signature Date
(Version #120803) |
345 Cleveland Street, Meeker, CO 81641
970-878-5047
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