HIPAA Notice of Privacy Practices
NOTICE EFFECTIVE DATE: May 1, 2007
REVISED DATE: January 1, 2013
CONTACT INFORMATION
If you have any questions about this notice, please contact Privacy Officer, CHRISTUS Southern New Mexico (CSNM) at PrivacyOfficer@gcrmc.org
WHO WILL FOLLOW THIS NOTICE
This notice describes the practices of CSNM and that of:
- Any health care professional authorized to enter information into your facility chart
- All departments and units of CSNM
- Any member of a volunteer group allowed to help you while you are receiving services from the facility
- All employees, staff, agents and other facility personnel
- All entities, sites and locations within this facility’s system will follow the terms of this notice. They also may share medical information with each other for purposes of treatment, payment and health care operations.
OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
We understand that medical information about you and your healthcare is personal. We are committed to protecting medical information about you. A record is created of the care and services you receive at this facility. This record is needed to provide the necessary care and to comply with legal requirements. This notice applies to all of the records of your care generated by the facility. Your personal physician may have different policies or notices regarding the physician’s use and disclosure of your medical information in the physician’s office or clinic.
This notice will tell about the ways in which the facility may use and disclose medical information about you. Also described are your rights and certain obligations we have regarding the use and disclosure of medical information.
The law requires the facility to:
- Make sure that medical information that identifies you is kept private;
- Inform you of our legal duties and privacy practices with respect to medical information about you; and
- Follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe different ways that we may use and disclose your health information. For each category we will explain what we mean and in some instances provide an example. Not every use or disclosure will be listed. However, all of the ways we are permitted to use and disclose your health information will fall within one of the following categories.
Treatment
We may use or disclose your health information in the normal course of providing you with necessary services. For example, we may ask you to undergo laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We may use your health information to write a prescription for you, or we may disclose your health information to a pharmacy when we call and order a prescription for you. Many people who work for our facility – including doctors and nurses, may use or disclose your health information in order to treat you or to assist others in your treatment.
Payment
We may use and disclose your health information to bill and collect payment for the services and items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover your treatment costs. Also, we may use your health information to bill you directly for services and items.
Healthcare Operations
We may use and disclose your health information for operational purposes, that is, for use by CSNM staff other than those providing services or items. For example, our quality improvement department may use your health information to evaluate the performance of our staff, assess the quality of care and outcomes in your case and in similar cases and to determine how we may continually improve the quality and effectiveness of the services we provide. Other examples of how we may use your information for operational purposes include:
- Determining additional services the facility should offer, what services are not needed, and whether certain new treatments are effective.
- Disclosing to doctors, nurses, technicians, students and other agents of the facility for review and learning purposes.
- Combining with information from other facilities to compare how we are doing and see where we can improve the care and services offered. Information that identifies you in this set of medical information may be removed so others may use it to study health care and health care delivery without knowing who the specific patients are.
Individuals Involved in Your Care
With your permission, your medical information may be released to a family member, guardian or other individuals involved in your care. They may also be told about your condition unless you have requested additional restrictions.
Hospital Directory
We may include your name, location in the hospital, general health condition and religious affiliation in a patient directory without receiving your permission unless you tell us you do not want your information in the directory or unless you are located in a specific ward, wing, or unit that would indicate that you are receiving treatment for a mental illness or developmental disability, HIV/AIDS or substance abuse. Information in the directory may be shared with anyone who asks for you by name. If you object to having your information shared, we will not be able to tell your family or friends that you are in the hospital.
Clergy Members
While you are a patient in the facility information about you may be disclosed to your specific clergy. This information may include your name, address, and admission date.
As Required by Law
Your medical information will be disclosed when required to do so by federal, state, or local authorities, laws, rules and/or regulations. Instances may include:
- Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, your medical information will be disclosed in response to a court or administration order, subpoena, discovery request, or other lawful process by someone else involved in the dispute when we are legally required to respond.
- Law Enforcement. Your medical information will be released if requested 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; 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.
- National Security and Intelligence Activities. Your medical information will be released to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
- To Avert a Serious Threat to Health or Safety. Your medical information may be used and disclosed when necessary to prevent a serious threat to your health and safety and that of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
- Health Oversight Activities. Your medical information may be disclosed to a health oversight entity 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 health care system, government programs, and compliance with civil rights laws.
Private Accreditation Organizations – Your medical information may be used to fulfill this facility’s requirements to meet the guidelines of private facility accreditation organizations such as the DNV, NCQA, etc.
Health-Related Benefits and Services – Your medical information may be used to tell you about health-related benefits or services that may be of interest to you.
Census Information
Limited information about you may be used in the census report while you are a patient of the facility. This information may include your name, location of the facility, admission date and address.
Appointment Reminders
Your medical information may be used to contact you as a reminder of an appointment you have for treatment or medical care from the facility.
Research
We may use or disclose your health information for research purposes pursuant to your signed authorization, or with institutional review board or privacy board approval.
SPECIAL SITUATIONS
Organ and Tissue Donation
If you are an organ or tissue donor, your medical information may be released to organizations that handle organ procurement or organ, eye and tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Medical Devices
Your social security number and other required information will be released in accordance with federal laws and regulations to the manufacturer of any medical device(s) you have implanted or explanted during a hospitalization and to the Food and Drug Administration, if applicable. This information may be used to locate you should there be a need with regard to such medical device(s).
Military and Veterans
If you are a member of the armed forces, your medical information may be released as required by military command authorities. If you are a member of the foreign military personnel, your medical information may be released to the appropriate foreign military authority.
Workers’ Compensation
If you seek treatment for a work-related illness or injury, we must provide full information in accordant with state-specific laws regarding workers’ compensation claims. Once state-specific requirements are met and an appropriate written request is received, only the records pertaining to the work-related illness or injury may be disclosed.
Public Health Risk
Your medical information may be used and disclosed 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 a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or
- 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.
Coroners, Medical Examiners, and Funeral Directors
Your medical information may be released 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 facility to funeral directors as necessary to carry out their duties.
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 for the following reasons:
- For the institution to provide you with health care;
- To protect the health and safety of you and others; and
- For the safety and security of the correctional institution.
OTHER USES OR DISCLOSURES
Uses or disclosures of your health information other than those identified in this notice will be made only with your written authorization. You may revoke that authorization at any time.
YOUR HEALTH INFORMATION RIGHTS
You have the following rights regarding the health information we create and maintain about you:
- You have a right to request a restriction/limitation on the medical information we use or disclose about you for treatment, payment or health care 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. CSNM is not required to agree to such a request. You also have a right to request that a health care item or service not be disclosed to your health plan for payment purposes or health care operations. We are required to honor your request if the item or service is paid out of pocket and in full. You may cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.
- To request that we communicate with you about health matters in a certain way. For example, you can ask that we only contact you at work or by mail;
- To inspect and obtain a paper or electronic copy (as applicable) of your health information (please note that CSNM may charge a fee for providing the information to cover the costs of copying the material, labor, supplies, and postage.
- To receive a paper copy of this notice in addition to viewing it on our Web site at www.CHRISTUS Health.org;
- To request an amendment of incorrect or incomplete information in your health record; and
- To receive an accounting of certain disclosures made to entities outside of CSNM.
All requests must be submitted in writing. Electronic links to required forms may be found at the end of this notice.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with CHRISTUS Southern New Mexico or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. CHRISTUS Southern New Mexico will investigate all complaints promptly and thoroughly. You will not be retaliated against for filing a complaint.
Forms for making any requests referenced in this notice or for filing a complaint may be obtained from our Web site at www.gcrmc.org or by contacting the CHRISTUS Southern New Mexico Privacy Officer.
CHRISTUS Southern New Mexico’s OBLIGATIONS TO YOU
CHRISTUS Southern New Mexico is required by law to:
- Maintain the privacy of your health information;
- Provide you with this notice of its legal duties and privacy practices with respect to your health information;
- Abide by the terms of this notice;
- Notify you if we are unable to agree to a requested restriction on how your health information is used or disclosed;
- Accommodate reasonable requests you may make to communicate health information as requested; and
- Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted by law.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and its practices. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our Web site at www.gcrmc.org. The notice will contain the effective and revision dates on the first page. In addition, the first time you register or are admitted for treatment or health care services or items following the effective and revision date(s), we will offer you a copy of the current notice in effect.
Request for Restriction and/or Confidential Communications
Request for Health Information
Request for Amendment of Health Information
