NOTICE OF PRIVACY PRACTICES
Effective Date: 04-14-2003
In accordance with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
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.
WHO WILL FOLLOW THIS
NOTICE:
This notice describes our hospital’s
practices and that of:
Ø
Any
healthcare professional authorized to enter information into your
hospital chart.
Ø
All
departments and units of the hospital.
Ø
Any
member of a volunteer group we allow to help you while you are in
the hospital.
Ø
All
employees, staff and other hospital personnel.
Ø
All these
entities, sites and locations follow the terms of this notice. In
addition, these entities, sites and locations may share medical
information with each other for treatment, payment or hospital
operations purposes described in this notice.
OUR PLEDGE
REGARDING MEDICAL INFORMATION:
We are required
by law to:
·
make sure
that medical information that identifies you is kept private;
·
give you
this notice of our legal duties and privacy practices with respect
to medical information about you; and
·
follow
the terms of our Notice of Privacy Practices that is currently in
effect.
Ø
For
Treatment.
We may use medical information about you to provide you with
medical treatment or services. We may disclose medical information
about you to doctors, nurses, technicians, medical students, or
other personnel who are involved in taking care of you. 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 family members, clergy, long term care
facility personnel, or others we use, or work together with, to
provide services that are part of your care.
Ø
For
Payment.
We may use and disclose medical information about you so that the
treatment and services you receive at the hospital may be billed
to and payment may be collected from you, an insurance company or
a third party. For example, we may need to give your health plan
information about surgery you received at the hospital so your
health plan will pay us or reimburse you for the surgery. We may
also tell your health plan about a treatment you are going to
receive to obtain prior approval or to determine whether your plan
will cover the treatment.
Ø
For
Healthcare Operations.
We may use and disclose medical information about you for hospital
operations. These uses and disclosures are necessary to run the
hospital and make sure that all of our patients receive quality
care. For example, we may use medical information to review our
treatment and services and to evaluate the performance of our
staff in caring for you. We may also combine medical information
about many hospital patients to decide what additional services
the hospital should offer, what services are not needed, and
whether certain new treatments are effective. We may also disclose
information to doctors, nurses, technicians, medical students, and
other hospital personnel for review and learning purposes. We may
also combine the medical information we have with medical
information
from other hospitals to
compare how we are doing and see where we can make improvements in
the care and services we offer. We may remove information that
identifies you from this set of medical information so others may
use it to study healthcare and healthcare delivery without
learning who the specific patients are.
Ø
Activities of an Organized Health Care Arrangement in Which We
Participate.
For certain activities, the Hospital, members of its Medical Staff
and other independent professionals are called an Organized Health
Care Arrangement. We may disclose information about you to
healthcare providers participating in our Organized Health Care
Arrangement, such as a managed care or physician-hospital
organization. Such disclosures would be made in connection with
our services, your treatment under a health plan arrangement, and
other activities of the Organized Health Care Arrangement.
IMPORTANT NOTICE
The Hospital may share
your medical information with members of the Hospital Medical
Staff and other independent medical professionals in order to
provide treatment and perform other activities such as peer
review, quality improvement, medical education and other services
for the Hospital. While those professionals may follow this Notice
and otherwise participate in the privacy program of the Hospital,
they are independent professionals. Neither Party assumes any
liability or other obligations incurred by the other Party.
It is further understood that
participation in the Organized Health Care Arrangement in no way
creates, nor shall it be construed as creating any type of
employment, partnership, joint venture, franchise or other
relationship between the Parties, other than that of independent
contractors and that each Party expressly disclaims any
responsibility or liability for the other Parties acts, errors,
and/or omissions.
Ø
Appointment Reminders.
We may use and disclose medical information to contact you as a
reminder that you have an appointment for treatment or medical
care.
Ø
Treatment Alternatives.
We may use and disclose medical information to tell you about or
recommend possible treatment options or alternatives that may be
of interest to you.
Ø
Health-Related Benefits and Services.
We may use and disclose medical information to tell you about
health-related benefits or services that may be of interest to
you.
Ø
Fundraising Activities.
We may use information about you to contact you in an effort to
raise funds for the hospital. We may disclose demographic
information to the CRMC hospital foundation so that the foundation
may contact you in raising money for the hospital. We would only
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
fund-raising efforts and you wish to have your name removed from
the list to receive fund-raising requests supporting the hospital
in the future, you must notify
CRMC Foundation, Attn: Executive Director, P.O. Box 305,
Coffeyville, KS 67337 in writing. In the event you contact us
with this request, all reasonable efforts will be taken to ensure
you will not receive any fund-raising communications from us in
the future.
Ø
Hospital Directory.
We may include certain limited information about you in the
hospital directory while you are a patient at the hospital. This
information may include your name, location in the hospital, your
general condition (e.g., fair, stable, etc.) and your religious
affiliation. The directory information, except for your religious
affiliation, may also be released to people who ask for you by
name. Your 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. This is so your family, friends and clergy can visit you
in the hospital and generally know how you are doing.
Ø
Individuals Involved in Your Care or Payment for Your Care.
We may release medical information about you to a friend or family
member who is involved in your medical care.We may also give
information to someone who helps pay for your care. We may also
tell your family or friends your condition and that you are in the
hospital. In addition, we may disclose medical information about
you to an entity assisting in a disaster relief effort so that
your family can be notified about your condition, status and
location.
Ø
Research.
Under certain circumstances, we may use and disclose medical
information about you for research purposes. For example, a
research project may involve comparing the health and recovery of
all patients who received one medication to those who received
another, 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 medical information,
trying to balance the research needs with patients' need for
privacy of their medical information. Before we use or disclose
medical information for research, the project will have been
approved through this research approval process. However, we may
disclose medical information about you to people preparing to
conduct a research project, for example, to help them look for
patients with specific medical needs, so long as the medical
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
hospital.
Ø
As
Required By Law.
We will disclose medical information about you when required to do
so by federal, state or local law.
Ø
To
Avert a Serious Threat to Health or Safety.
We may use and disclose medical information about you when
necessary to prevent a serious threat to your health and safety or
the health and safety of the public or another person. Any
disclosure, however, would only be to someone able to help prevent
the threat.
SPECIAL
SITUATIONS:
Ø
Organ and Tissue Donation.
If you are an organ donor, we may release medical information to
organizations that handle organ procurement or organ, eye or
tissue transplantation or to an organ donation bank, as necessary
to facilitate organ or tissue donation and transplantation.
Ø
Military and Veterans.
If you are a member of the armed forces, we may release medical
information about you as required by military command authorities.
We may also release medical information about foreign military
personnel to the appropriate foreign military authority.
Ø
Workers' Compensation.We
may release medical information about you for workers'
compensation or similar programs. These programs provide benefits
for work-related injuries or illness.
Ø
Public Health Risks.
We may disclose medical information about you for public health
activities. These activities generally include the following:
·
to
prevent or control disease, injury or disability;
·
to report
births and deaths;
·
to report
child abuse or neglect;
·
to report
reactions to medications or problems with products;
·
to notify
people of recalls of products they may be using;
·
to notify
the
statewide
trauma registry
·
to notify
a person who may have been exposed to a disease or may be at risk
for contracting or spreading a disease or condition;
·
to notify
the appropriate government authority if we believe a patient has
been the victim of abuse, neglect or domestic violence. We will
only make this disclosure if you agree or when required or
authorized by law.
Ø
Health Oversight Activities.
We may disclose medical information to a health oversight agency
for activities authorized by law. These oversight activities
include, for example, audits, investigations, inspections, and
licensure. These activities are necessary for the government to
monitor the healthcare system, government programs, and compliance
with civil rights laws.
Ø
Lawsuits and Disputes.
If you are involved in a lawsuit or a dispute, we may disclose
medical information about you in response to a court or
administrative order. We may also disclose medical information
about you in response to a subpoena, discovery request, or other
lawful process by someone else involved in the dispute, but only
if efforts have been made to tell you about the request or to
obtain an order protecting the information requested.
Ø
Law
Enforcement.
We may release medical information if asked to do so by a law
enforcement official:
·
In
response to a court order, subpoena, warrant, summons or similar
process;
·
To
identify or locate a suspect, fugitive, material witness, or
missing person;
·
About the
victim of a crime if, under certain limited circumstances, we are
unable to obtain the person's agreement;
·
About a
death we believe may be the result of criminal conduct;
·
About
criminal conduct at the hospital; and
·
In
emergency circumstances to report a crime; the location of the
crime or victims; or the identity, description or location of the
person who committed the crime.
Ø
Coroners, Medical Examiners and Funeral Directors.
We may release medical information to a coroner or medical
examiner. This may be necessary, for example, to identify a
deceased person or determine the cause of death. We may also
release medical information about patients of the hospital to
funeral directors as necessary to carry out their duties.
Ø
National Security and Intelligence Activities.
We may release medical information about you to authorized federal
officials for intelligence, counterintelligence, and other
national security activities authorized by law.
Ø
Protective Services for the President and Others.
We may disclose medical information about you to authorized
federal officials so they may provide protection to the President,
other authorized persons or foreign heads of state or conduct
special investigations.
Ø
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 healthcare; (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.
YOUR RIGHTS
REGARDING MEDICAL INFORMATION ABOUT YOU:
You have the following
rights regarding medical information we maintain about you:
Ø
Right to Inspect and Copy.
You have the right to inspect and copy medical information that
may be used to make decisions about your care. Usually, this
includes medical and billing records, but does not include
psychotherapy notes.
To inspect and copy medical information that may be used to make
decisions about you, you must submit your request in writing to:
Coffeyville Regional Medical Center, Attn: Release of
Information, 1400 West Fourth, Coffeyville, Kansas 67337. 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.
We may
deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information,
you may request that the denial be reviewed. Another licensed
healthcare professional(s) chosen by the hospital will review your
request and the denial. The person(s) conducting the review will
not be the person who denied your request. We will comply with
the outcome of the review.
Ø
Right to Amend.
If you feel that medical information we have about you is
incorrect or incomplete, you may ask us to amend the information.
You have the right to request an amendment for as long as the
information is kept by or for the hospital.
To
request an amendment, your request must be made in writing and
submitted to Coffeyville Regional Medical Center, Health
Information Management Department, Attn: Director Health
Information Management, 1400 West Fourth, Coffeyville, Kansas
67337. In addition, you must provide a reason that supports
your request.
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.
Ø
Right to an Accounting of Disclosures.
You have the right to request an "accounting of disclosures” which
is a list of the disclosures we made of medical information about
you.
To
request this list or accounting of disclosures, you must submit
your request in writing to Coffeyville Regional Medical Center,
Health Information Management Department, Attn: Release of
Information, 1400 West Fourth, Coffeyville, Kansas 67337. Your
request must state a time period, which may not be longer than six
years and may not include dates before April 14, 2003. 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.
Ø
Right to Request Restrictions.
You have the right to request a restriction or limitation on the
medical information we use or disclose about you for treatment,
payment or healthcare operations. You also have the right to
request a limit on the medical information we disclose about you
to someone who is involved in your care or the payment for your
care, like a family member or friend. For example, you could ask
that we not use or disclose information about a surgery you had.
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.
To request restrictions, you must make your request in writing to
Coffeyville Regional Medical Center, Health Information
Management Department, Attn: Release of Information, 1400 West
Fourth, Coffeyville, Kansas 67337. 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.
Ø
Right to Request Confidential Communications.
You have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. 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 Coffeyville Regional Medical Center, Health
Information Management Department, Attn: Release of Information,
1400 West Fourth, Coffeyville, Kansas 67337. 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.
Ø
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. Even if you have
agreed to receive this notice electronically, you are still
entitled to a paper copy of this notice.
To
obtain a paper copy of this notice, Coffeyville Regional
Medical Center, Health Information Management Department, Attn:
Release of Information, 1400 West Fourth, Coffeyville, Kansas
67337.
You may
also obtain an electronic copy of this notice at our website:
www.crmcinc.com
CHANGES TO
THIS NOTICE:
We reserve the right to
change the terms of this notice. We reserve the right to make the
revised or changed notice effective for all medical information we
already have about you i.e., prior to the effective date of the
notice revision, as well as any information we receive in the
future. 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. In addition, each time you register at
or are admitted to the hospital for treatment or healthcare
services as an inpatient or outpatient, we will offer to you a
copy of the current notice that is in effect.
COMPLAINTS:
You will not
be penalized or retaliated against for filing a complaint.
OTHER USES
OF MEDICAL INFORMATION:
Other uses and
disclosures of medical information not covered by this notice or
the laws that apply to us will be made only with your written
authorization, giving us permission for such uses and disclosures.
If you provide us permission to use or disclose medical
information about you, you may revoke that permission, in writing,
at any time. To revoke an authorization, contact Coffeyville
Regional Medical Center, Attn: Privacy Officer, 1400 West Fourth,
Coffeyville, Kansas 67337; 620-251-1200. If you revoke your
permission, we will no longer use or disclose medical information
about you for the reasons covered by your written 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 care that we
provided to you.
The
ability or inability to condition treatment, payment, enrollment
or eligibility for benefits on the authorization, by stating
either:
a.
CRMC may not condition treatment, payment, enrollment or
eligibility for benefits on whether the individual signs the
authorization when the prohibition on conditioning of
authorizations of this policy applies; or
b.
The consequences to the individual of a refusal to sign the
authorization when, in accordance with the prohibition on
conditioning of authorizations of this policy, CRMC can condition
treatment, enrollment in the health plan, or eligibility for
benefits on failure to obtain such authorization.
Authorization for Treatment, Photography, Financial
Responsibility, and Conditions of Admission
Acknowledgement of Receipt of Notice of Privacy Practices
MEDICAL CONSENT:
I, the undersigned, hereby voluntarily authorize CRMC, the
physician of my choice, his assistants, or his designees to
perform necessary treatment, procedures, or photographs as he
deems appropriate for my condition. I also consent to the
administration of necessary anesthetics. Any tissue removed may be
disposed of by the medical center in accordance with the law and
accustomed practice. I fully understand this authorization,
reasons for treatment or surgery, complication and alternatives. I
am aware that the practice of medicine is not an exact science and
I acknowledge that no guarantees have been made to me as a result
of treatments or examination in the medical center. My use of any
narcotics, drugs, or medicines will be subject to medical center
control, and I agree that all such narcotics, drugs or medicines
will be kept in the medical center’s possession to be dispensed in
accordance with the medical center’s rules and regulations.
This consent is designed to cover
all procedures in the medical center, which do not require a
“Special Consent Form”.
BLOOD TESTING:
I consent to having the medical center, its employees and the
“physician of my choice, assistants or designees” test my blood as
necessary, and using the information to protect the health of my
family, my health care workers, or myself.
STATEMENT OF PERSONAL VALUABLES:
I acknowledge that the medical center maintains a safe for the
safekeeping of money and valuables and the medical center shall
not be liable for the loss of or damage to my money, jewelry,
glasses, dentures, documents or other articles of unusual value
and small size unless placed in the safe, and shall not be liable
for loss or damage to any other personal property, unless
deposited with the medical center for safekeeping.
FINANCIAL AGREEMENT AND ASSIGNMENT
OF BENEFITS: In
consideration of the services to be rendered to the patient, I
hereby assign to the medical center and my physician, to any
extent necessary to satisfy my outstanding indebtedness, if any,
all sums payable to me pursuant to my health benefit plan, policy
of insurance (including, but not limited to health, liability,
uninsured or underinsured motorist or medical insurance) and/or
any amount due or received pursuant to any settlement or judgment
arising out of or related to any incident, which caused the
patient’s admission or medical treatment.
I understand
that I am responsible for any health insurance deductibles or
co-insurances of the applicable percentage of the remaining
charges. I understand that I am financially responsible to the
medical center and the physician for any and all charges
regardless of whether covered by a third party payer source.
In exchange
for all services rendered to the patient, whether rendered at a
single visit or on a continuous basis, or rendered to any infant(s)
born during this admission, the undersigned agrees whether he or
she signs as agent or personal representative of the patient or as
the patient, that he or she hereby assumes full responsibility and
agrees and promises to pay the medical center and physicians the
full amount charged for these services. It is agreed that if this
indebtedness is placed in the hands of any collection agency or
attorney for collection, I will pay reasonable collection costs,
including late charges, interest, and attorney fees or collection
agency fees as provided by Kansas law.
It is
expressly understood that, as used in the paragraph, the term “I”,
“me”, or “my” shall, where appropriate, refer to any and all legal
representatives of the patient and guarantors executing this form.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:
Our Notice of Privacy Practices provides information about how we
may use and disclose protected health information about you. You
have the right to review our notice before signing this
acknowledgement. As provided in our notice, the terms of our
notice may change. If we change our notice, you may obtain a
revised copy by submitting a request in writing to:
Coffeyville Regional Medical Center, Attn: Privacy Officer, 1400
West Fourth, Coffeyville, Kansas 67337; 620-251-1200; or you
may obtain a copy of this notice at our website, www.crmcinc.com.
The undersigned certifies that they
has read the foregoing and is the patient, or is duly authorized
by the patient as the patient’s general agent to execute the above
and accepts its terms on behalf of the patient.
I have received a copy of my
“Patient Rights and Responsibilities”. I acknowledge receipt of
Coffeyville Regional Medical Center’s “Notice of Privacy
Practices”.
Signature or Initials of Patient or
Patient’s Authorized Representative Date
___________________________________________________________
Printed name
of patient’s authorized representative
Relationship
to patient:
______________________________________________________________
