ST. MARY’S HOSPITAL & MEDICAL CENTER

NOTICE OF PRIVACY PRACTICES

Effective June 15, 2007

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS YOUR INFORMATION.
PLEASE REVIEW IT CAREFULLY.

St. Mary’s Hospital and Medical Center (St. Mary’s) and its Organized Health Care Arrangement (“OHCA”), including our affiliated physicians and other licensed healthcare professionals, are authorized to use and disclose your health information as permitted by federal and state privacy laws.

St. Mary’s CommitmentTo Safeguard Your Protected Health Information (PHI)

PHI includes informa­tion that we create or receive about your past, present, or future physical or mental health as we provide your care and information that can be used to identify you. PHI may include documentation of your symptoms, examination and test results; your diagnoses and treatment; and information concerning future care or treatment. It also includes documents related to billing and payment for care provided. 

We are required by law to maintain the privacy of your PHI and provide you with notice of our privacy practices which explains how, when, and why we use and disclose PHI.

St. Mary’s participates in Quality Health Network, a regional health information network.  This is a centralized electronic database which contains PHI from a variety of health care service providers including hospitals, physician offices, health insurance companies and pharmacies. All network members are subject to the HIPAA Privacy laws. By participating in this network and additional centralized electronic databases, St. Mary’s intends to provide timely information to those health care and related service providers who may be involved in your care.

Signing An Acknowledgement

You will be asked to sign a statement that you have received this Notice of Privacy Practices. We are required by law to make a good faith effort to provide you with our Notice of Privacy Practices and obtain your acknowledgement that we have done so.  However, you do not need to sign the statement to receive care here at St. Mary’s. 

Examples of Uses of Your PHI for Treatment:

• A nurse or medical assistant obtains treatment information about you and records it in your medical record. 
• A doctor in the emergency room may need to consult with your primary care physician. He/she will share information with the primary care physician in order to obtain his/her input.
• We may call or send you a reminder to schedule an appointment or contact you to confirm an existing appointment.
• A doctor in his/her office may review your lab results in Quality Health Network’s database.

Examples of Use of your PHI for Payment:

• When our finance office bills your health insurance company, we may be asked to give them information about surgery or other care you received so the bill will be paid. 
• Our registration clerk may contact your insurance company to obtain prior approval for a treatment or to determine whether it is covered by your plan.
• Your doctor may request copies of your hospital medical record to assist his or her office when billing for the physician services provided while you were at St. Mary’s.

Examples of Use of your PHI for Health Care Operations:

• St. Mary’s quality improvement office or Medical Staff office may use PHI in order to evaluate the quality of our health care services, to develop standards of care or to evaluate the performance of health care professionals.
• Our planning office may combine medical information about many hospital patients to determine the services the hospital should offer.
• We provide PHI to our business associates, including accountants, attorneys, and consultants. We require them to safeguard the privacy of this information.

Your Health Information Rights

The medical and billing records we maintain are the physical property of St. Mary’s.  The information in it, however, belongs to you.

Requests for any of the actions listed below must be in writing. A form for each is available for your use. These forms can be found at the registration desks and in our medical records department.

Your requests will be carefully considered. St. Mary’s will respond to your request in writing in a timely manner. In certain situations, St. Mary’s may deny a request due to legal considerations or business reasons.

You have a right to:

Receive a copy of your PHI. An authorization form is available from the Health Records Department. A fee will be charged for the costs of copying, mailing, or other supplies and services associated with your request. A fee schedule is available in the Health Records Department.

Request a restriction on certain uses or disclosures (i) to someone who is involved in your care or the payment for your care, like a family member or friend, (ii) of information from the hospital’s patient directory; or (iii) of information for marketing or fundraising purposes. We may not be able to honor restrictions in emergency treatment situations.

Request that we correct the record if you believe that your PHI is incorrect or incomplete.

Obtain an accounting of certain disclosures of your PHI that we are required to maintain. Your written request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. You will be charged our costs for providing any additional lists within this 12-month period.

The list we will give you will include the date of each applicable disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure.

The list will not include every use or disclosure. Not included are those made to you or at your request; those made for treatment, payment or operations; those made in our patient directory; or those made to family members or friends relevant to that person’s involvement in your care or in payment for such care. 

Request in writing that communication of your health information (i.e. bills, appointment reminders) be made by alternative means or at an alternative location. 

Revoke Permission. We will ask for your written permission before we use your PHI for a purpose not otherwise permitted under federal or state law. Once you have given us your permission to use or disclose your PHI for a particular reason, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your PHI for reasons stated; however, we cannot take back any disclosures we have already made based upon your prior permission.

A paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.  Your request can be in person or over the phone – no written request is needed.  Paper copies are available at all registration locations and the Health Records Department.  Or, you may contact our Privacy Officer. You may also obtain a copy of this Notice on our website at www.stmarygj.com.

Additional Disclosures and Uses Permitted by Law

Communication with Family.  If you do not object or in an emergency, we may, using our best judgment, disclose PHI to a family member, other relative, close personal friend, or other person who is involved in your care or the payment for your health care.
We may also tell your family and/or friends your condition and that you are in the hospital.  If a disaster occurs, we may disclose PHI to an organization assisting in a disaster relief effort so your family can be notified about your condition, status and location. You may ask to limit what information is provided and/or to whom by filling out the form “Patient Request for Restriction on the Use and Disclosure of PHI” available at all registration locations or from the Health Records Department, 970-244-2510, located in the main Hospital building.

Patient Directory (Inpatients). We include certain limited information (name, room number, general condition [good, fair, serious, and critical], and your religious affiliation) in our patient directory while you are an inpatient at St. Mary’s. The directory information, except for your religious affiliation, will be released to people who ask for you by name.  The directory information including your religious affiliation will be given to a member of the clergy (such as a priest, minister, rabbi) or church designated visitor even if they don’t ask for you by name. You will be asked about having your name in the directory at the time of registration.  You may also limit or exclude your information from this directory by filling out the form “Patient Request for Restriction on the Use and Disclosure of PHI” available at all registration locations or from the Health Records Department, 970-244-2510, located in the main Hospital building.  Exclusion from the directory means friends, family and/or florists will not be given any information about you on the phone or at the front desk.

Traditional Hospital Activities.  It is common practice for St. Mary’s to use or disclose very limited PHI (i.e. name, room number, mailing address) to hospital or St. Mary’s Foundation staff for traditional recognition uses such as invitations to specific patient group reunions such as cancer survivor events and donor appreciation.

Minors’ PHI.  As a general rule, we release PHI about minors to their parents or legal guardians.  However, in instances where Colorado law allows minors to consent to their own treatment without parental consent (i.e., HIV testing), information will not be released to a minor’s parents without the minor’s consent unless otherwise specifically allowed under Colorado law. 

Mental Health Records. The use and disclosure of information obtained and records prepared in the course of providing mental health services are protected by Colorado State law and regulations. We may communicate information between qualified professionals providing services or upon appropriate referrals, for payment purposes or upon court order.  Otherwise, we may not release any information without your specific consent.

Media Requests. All requests regarding your condition or contacts made by the media must be referred to St. Mary’s Public Relations Department. Contact the Department at 970-244-2000 to discuss the handling of media requests or to designate a person of your own choosing to respond to such requests.

Philanthropic Activities. St. Mary’s Hospital Foundation may use certain limited information (name, address, telephone or fax number, dates of service, age and gender only) to contact you in an effort to raise funds for the hospital. If you do not wish to be contacted for fundraising efforts, notify the Privacy Officer in writing. Forms for requesting limits on uses and disclosures are available at all registration locations or from the Health Records Department.

Miscellaneous:

• Research (requests to use information for research projects are subject to a special approval process);
• To avert a serious threat to health or safety to the public or another person; 
• When specific to a lawsuit or dispute;
• To governmental officials for public health activities (such as births, deaths, drugs, medical devices and various diseases);
• To agencies that oversee health activities (such as audits, investigations, inspections, and licensure); 
• To organ donation and transplant organizations;
• To your workers’ compensation program;
• To military command authorities and the Department of Veteran Affairs (applies to military and veterans); 
• To your employer when services have been provided at the employer’s request;
• For purposes of national security and intelligence;
• To correctional institutions or law enforcement officials (applies to inmates and those under arrest);
• As required by law (examples include reports about victims of abuse, neglect or violence and product recalls).

CONTACT THE PRIVACY OFFICER FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If you have any questions about this Notice or wish to make a complaint about our privacy practices, please contact our Privacy Officer at 970-244-2329 or via e-mail at privacy.officer@stmarygj.org.  Formal complaints must be in writing. Forms are available at all registration locations or from the Health Records Department. Completed forms should be sent to the Privacy Officer, Health Records Department, St. Mary’s Hospital and Regional Medical Center, P. O. Box 1628, Grand Junction, CO  81502 or by fax to 970-255-6336.

Complaints

If you believe that we may have violated your rights with respect to your PHI, you may file a written complaint with the Privacy Officer at the address noted above. You also may send a written complaint to the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 515F, HHH Building, Washington, D.C. 20201 within 180 days of an alleged violation of your rights.  You will not be penalized for filing a complaint about our privacy practices. You will not be required to waive this right as a condition of treatment.

Changes

We reserve the right to change the terms of this Notice and our privacy policies at any time. The new terms will apply to PHI created or received before the change as well as future PHI. Before we make an important change to our policies, we will promptly change this Notice and post a new Notice in the Hospital’s main registration area.  In addition, when you register after the Notice has changed, we will offer you a copy of the new Notice.  You can also request a copy of this Notice from the Privacy Officer at any time or can view a copy of the Notice on our website at www.stmarygj.com.
---------------------------------------------------------------------------------------
 

ST. MARY'S HOSPITAL
PO Box 1628, Grand Junction, Colorado 81502-1628
HIPAA - Acknowledgement of Receipt . . Notice of Privacy Practices ACK

Medical Record Number #: ____________

Account #: ________________________

Printed Patient Name:
___________________________________

I hereby acknowledge that I have received a copy of St. Mary's Hospital and its
Organized Health Care Arrangement’s Notice of Privacy Practices.  

Date:

______________________

Signature of patient or patient's representative:

______________________

Printed name of patient's representative:

____________________________________

Relationship to the patient:

____________________________________

Route form to HRIS Attn: Scanning 
Form# 30-05-201
April 2003