Notice of Privacy
Practices
SPRINGBROOK HOSPITAL
NOTICE OF PRIVACY PRACTICES
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.
1. Our responsibilities to safeguard
your protected health information.
- We are required by law to maintain the
privacy of your protected health information.
- We are required to provide you with this
notice about the hospital’s legal duties and privacy practices.
This notice explains how your protected health information may
be used, whom it may be disclosed to, and when it may be
disclosed. In each case, the hospital staff may only disclose
the minimum necessary protected health information to accomplish
the purpose of the disclosure.
- We are legally required to abide by the
terms of the privacy practices described in this notice.
- We are required to tell you that the
hospital board and management reserve the right to change the
terms of this notice and its privacy policies at any time. Any
changes will apply to the protected health information
previously created. Should an important change be made to our
privacy practices, a revised copy of the notice will be posted
in the following locations, Outpatient Registration and Lobby,
on the date it will go into effect. A copy of the notice can be
obtained from the hospital’s Privacy Officer at the address
listed in section five below.
2. How your protected health information
may be used.
We use health information about you for
treatment purposes, to obtain payment for treatment, and for
healthcare operations such as evaluating the quality of care that
you receive.
A. For some of these uses or disclosures, we
do not need your prior authorization. Below, we describe the
different categories of our uses and disclosures that do not need
your authorization and give you some examples of each category.
- For treatment. For example, information
obtained by a nurse, physician, or other member of your
healthcare team will be recorded in your record and used to
determine the best course of treatment for you. Members of your
healthcare team will record the actions they took and their
observations. The sharing of your protected health information
among your healthcare team is a key component of your
treatment. The hospital will provide your physician or your
other healthcare providers with copies of reports and results
that should assist them in treating you after you leave the
hospital.
- To obtain payment for treatment. Your
protected health information will be used to obtain payment for
your treatment. For example, your protected health information
such as diagnosis, procedures performed, and supplies used will
be included on the billing information sent to your health plan
in order to obtain payment. In some instances, your protected
health information may be provided to a business associates who
provides billing services for the hospital.
- For health care operations. Members of
the medical staff, the risk management staff, or quality
improvement staff may use information in your health record to
assess the care and results in your treatment and others like
it. This information will then be used in an effort to
continually improve the quality and effectiveness of the
healthcare and services the hospital provides.
B. There are certain uses and disclosures that
do not require your authorization. We may use and disclose your
protected health information without your authorization for the
following reasons:
- Organ donation. We may disclose, as
allowed by law protected health information to organization that
handle organ, eye, or tissue procurement, banking, or
transplantation of organs.
- Legal Proceedings. We may disclose
protected health information in response to a court order as the
result of a lawsuit or similar proceeding.
- Law enforcement. We may disclose
protected health information for law enforcement purposes as
required by law or in response to a valid subpoena. For
example, we may be required to report information to law
enforcement personnel about victims of a crime or domestic
violence.
- Information regarding the deceased. We
may provide coroners and medical examiners with protected health
information to assist in identifying the cause of death. We may
provide funeral directors the necessary protected health
information authorized by law to allow them to perform their
job.
- Health oversight activities. We may
disclose protected health information for health care oversight
agencies’ activities authorized by law, such as audits,
investigations, and inspections.
- Research purposes. We may provide patient
protected health information in order to conduct medical
research in certain situations as approved by an institutional
review board or privacy board.
- Military Activity. We may disclose
protected health information of armed forces personnel as
required by law or to the appropriate authorities.
- National Security purposes. We may
disclose protected health information to authorized federal
officials for national security and intelligence purposes,
including protecting the President of the United States or
others legally authorized.
- Correctional Institution. We may disclose
the protected health information of an inmate at a correctional
institution to the institution or its authorized agents for the
purposes of protecting the health and safety of the inmate or
other individuals.
- Fundraising activities. Patient protected
health information may be used for the hospital’s fundraising
activities. If you do not wish to be contacted as part of our
fundraising efforts, please contact the hospital Privacy Officer
whose address and phone number can be found in section five
below.
- For worker’s compensation purposes. We
may provide patient protected health information to the extent
authorized by and necessary to comply with workers’ compensation
or other similar programs established by law.
- Appointment reminders. We may use
protected health information to provide information about health
related benefits or services that may be of interest to you.
C. There are certain uses and disclosures to
which you will have the opportunity to object.
In the following situations we may disclose
your protected health information if we inform you about the
disclosure in advance and you do not object. If there is an
emergency and you cannot be given the opportunity to object, we may
disclose your health information consistent with any prior expressed
wishes if it is determined by a healthcare professional that it is
in your best interest, If you are unable to consent in an emergency,
you will be given the opportunity to object as soon as you are able
to do so.
- Hospital directories. Unless you object
in whole or in part, we will include your name, location in the
hospital, general condition, and religious affiliation, in the
hospital’s patient directory. This information will be
disclosed to people who ask for you by name. Your religious
affiliation may be disclosed to the clergy.
- Others involved in your healthcare.
Unless you object, we may provide your protected health
information to a family member, friend, or other person that you
identify that is involved in your care. If you are unable to
agree or object, we may disclose protected health information if
we feel, based on our professional judgment that it is in your
best interest.
D. All other uses and disclosures require your
prior written authorization.
Other uses and disclosures of your protected
health information will be made only with your written authorized,
unless otherwise permitted or required by law as described above.
You may revoke this authorization, at any time, in writing, except
to the extent that the hospital has already taken action in reliance
on the use or disclosure indicated in the authorization.
3. Your rights regarding your protected
health information.
- You have the right to request that we
restrict the use of your protected health information. Your
request must be in writing and state the specific restriction
requested and to whom you want the restriction to apply. The
hospital is not required to agree to a restriction that you may
request. If staff feels that it is not in your best interest to
restrict the disclosure of your protected health information,
your protected health information will not be restricted. If
the hospital agrees to your requested restriction, we may not
use or disclose your protected health information in violation
of that restriction unless it is for emergency treatment. All
requests to restrict protected health information must be
forwarded to the hospital’s Privacy Officer (address found in
section five below).
- You have the right to request to receive
confidential communications from us by alternate means (fax,
e-mail instead of direct mail) or at an alternate location
(sending information to another address rather than your home
address). We will accommodate reasonable request. All requests
must be directed to the hospital’s Privacy Officer at the
address indicated in section five below.
- Except in certain circumstances, you have
the right to inspect and copy your protected health
information. You may inspect and obtain a copy of your
protected health information for as long as we maintain the
protected health information.
You must make your
request in writing to the hospital’s Privacy Officer. In certain
situations, we may deny your request. We will provide our reasons
for denial to you in writing. If you disagree with our reasons for
denial, you have a right to appeal that decision.
Under federal law,
you may not inspect or copy the following records; psychotherapy
notes; information compiled in reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding, and
protected health information that is subject to law that prohibits
access to protected health information.
You will be charged $1.00 for each page
copied. We may provide you with a summary or explanation of the
information requested as long as you agree to that format and to the
cost in advance.
You have the right to
receive an accounting of certain disclosures made of your protected
health information. This does not include disclosures made for
purpose of treatment, payment or healthcare operations as described
in this Notice. It does not include disclosures made to you, for
the hospital directory or to family members or friends involved in
your care. In addition, it will not include disclosures made to
corrections or law enforcement officials or for Nation Security
purposes, of for any disclosures prior to April 14, 2003.
Request for an
accounting of disclosures must be in writing and forwarded to the
hospital’s Privacy Officer. We are legally obligated to respond to
your request within 60 days from the date your request is received.
The list provided to you will be for the last six years unless you
request a shorter time period.
- You have the right to amend your protected
health information. If you feel there is an error or omission
in your protected health information, you have the right to
submit a written request that the hospital correct your record.
All requ4ests for
amendment must be provided in writing to the hospital’s Privacy
Officer. We are required by law to respond to your request in 60
days of receipt of the request.
If we accept your
request, the change will be made to your protected health
information and you will receive written notice that it has been
completed. We will also notify others, if you agree, who may have
received the protected health information and may be relying on the
information to your detriment.
In certain instances,
we may deny your request to amend your medical record. A written
denial will be provided to you stating the reasons your request was
denied. If we deny your request, you have a right to provide a
statement of disagreement to the hospital’s Privacy Officer that
will be filed in your medical record. The hospital has the right to
prepare a rebuttal to your statement of disagreement to be filed in
your medical record. A copy of our rebuttal will be provided to
you. If you do not file a statement of disagreement, you have the
right to request that your written request that your written request
and the hospital’s denial be filed in your medical record.
- You have the right to get a copy of this
notice by e-mail. Even if you have agreed to receive notice via
e-mail, you also have the right to request a paper copy of this
notice.
4. How to complain about the hospital’s
privacy practices.
If you believe that someone at the hospital may
have violated your privacy rights, or if you disagree with a
decision we made about access to your protected health information,
you may file a complaint with the hospital Privacy Officer (see
section five below). You also may send a written complaint to the
Secretary of the Department of Health and Human Services at the
following address:
Secretary of the Department of Health and Human Services
The U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C./ 20201
(202) 619-0257
Toll Free: (877) 696-6775
We will take no retaliatory action against you
if you file a complaint about our privacy practices.
5. You may contact the hospital Privacy
Officer for information about this notice or to file a complaint.
If you have any questions about this notice or
would like to lodge a complaint about the hospital’s privacy
practices please contact the hospital Privacy Officer at:
Springbrook Hospital
7007 Grove Road
Brooksville, FL 34609
(352) 596-4306
6. Effective Date of this Notice
This notice went into effect on April 14, 2003
Acknowledgement of Receipt of Family Behavioral
Health Services of Hernando County, Inc. Notice of Privacy
Practices.
I have received a copy of this Notice of
Privacy Practices.
_________________________________
Signature of patient or legal representative
_________________________________
If signed by a legal representative, relationship to patient
_________________________________
Date Received
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