Privacy and HIPAA Policies
JOINT 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.
If you have any questions about this Notice please contact Johnston Health’s Privacy Officer at (919) 938-7121.
EFFECTIVE DATE: 04-14-03
Revised: 12-04-2008, 09-23-2013
All of the following entities, their 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 health care operations purposes described in this notice.
- Any health care professional authorized to enter information into your hospital chart including but not limited to: Physicians, Dentists, Physician Assistants, Nurse Practitioners, Health Care Students, Residents and Fellows.
- All entities of Johnston Health, including, but not limited to: Johnston Medical Center-Smithfield, Johnston Medical Center-Clayton, Johnston Medical Associates, Johnston Primary Care Physician Services, Inc., Johnston Specialty Physician Services, Inc., Johnston Therapeutic Wound Center, HealthQuest and Johnston Home Care & Hospice.
- Any member of a hospital volunteer group we allow to assist you.
- All hospital personnel, Board of Commissioners, and contract personnel.
We are required by law to maintain the privacy of “protected health information.” “Protected health information” includes any identifiable information that we obtain from you or others relating to treatment, payment, or health care operations.
This notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of protected health information. This notice also discusses the uses and disclosures we will make of your protected health information. We must comply with the provisions of this notice, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all protected health information we maintain. You can always request a copy of our most current privacy notice from our point of service registration department, Marketing & Community Relations Department, Johnston Health Privacy Officer, or you can access it on our website at www.johnstonhealth.org.
PERMITTED USES AND DISCLOSURES
Following are examples of the types of uses and disclosures of your protected health care information that may be made by the hospital.
Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services, including consultations between health care providers regarding your care and referrals for health care from one health care provider to another. 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. Therefore, the doctor may review your medical records to assess whether you have potentially complicating conditions like diabetes.
Payment. Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, prior to providing health care services, we may need to provide to your health plan information about your medical condition to determine whether the proposed course of treatment will be covered. When we subsequently bill the health plan for the services rendered to you, we can provide the health plan with information regarding your care if necessary to obtain payment.
Health care operations. We may use or disclose, as-needed, your protected health information in order to support the business activities of our hospital. This includes activities related to treatment and payment, such as quality assurance activities, case management, risk management, receiving and responding to patient complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities.
For example, we may disclose your protected health information to students that participate in patient care at the hospital. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, and transcription services) for the hospital. Whenever an arrangement between the hospital and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. We may use and disclose protected health information to tell you about our health-related products or services that may be of interest to you.
We may use or disclose your demographic information and the dates that you received treatment as necessary in order to contact you for fundraising activities supported by our Hospital. If you do not want to receive these materials, please contact Johnston Health’s Director of Marketing & Community Relations and request that these fundraising materials not be sent to you.
USES AND DISCLOSURES THAT MAY BE MADE WITH AN OPPORTUNITY TO OBJECT
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information in such instances. If you are not present or able to agree or object to the use or disclosure of the protected health information, then the Hospital may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Inpatient Facility Directory: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care and your condition (in general terms). If you do not wish to be included in the inpatient facility directory, please complete the applicable section of the Johnston Health Privacy Request Form. This form is available at any registration area, nursing unit, the Patient Services Office or from the Privacy Officer. A request to opt out of the inpatient facility directory is effective for the current visit and all future inpatient visits to our facility until revoked by the patient. A revocation must be made on the Johnston Health Privacy Revocation Form. This form is available in the same areas as the Johnston Health Privacy Request Form.
Inpatient Religious Affiliation Listing: Unless you object or do not provide your religious affiliation, we will maintain a listing of inpatients for each religious affiliation. The list will only contain the patients name and location. This list will be shared with ministers of that particular religious affiliation. We are allowed to do this to assist local clergy in identifying parishioners that the clergy member should visit. If you do not wish to be included in the listing for your religious affiliation, please inform a member of our staff and complete the Johnston Health Privacy Request Form.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Primary Care Physician: Unless you object, we will disclose your visit to our facility and applicable information related to your treatment to your primary care physician of record.
USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION OR OPPORTUNITY TO OBJECT
We may use or disclose your protected health information in the following situations without your authorization. These situations include:
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the hospital, and (6) medical emergency and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: Under certain circumstances, we may use and disclose protected health 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 protected health information for research, the project will have been approved through this research approval process, but we may, however, 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.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
USES AND DISCLOSURES BASED UPON YOUR WRITTEN AUTHORIZATION
All Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. Such uses and disclosures of your protected health information that will be made only with your written authorization, unless otherwise permitted or required by law, include most uses and disclosures of psychotherapy notes, most uses and disclosures for marketing purposes, and most disclosures that constitute the sale of your protected health information. You may revoke this authorization, at any time, in writing, except to the extent that the Hospital has taken an action in reliance on the use or disclosure indicated in the authorization. In order to authorize uses and disclosures of your protected health information other than those described in this notice, please complete the Johnston Health Authorization To Disclose Health Information Form that is available from our Health Information Management Department or the Privacy Officer. If you wish to revoke an authorization, you must complete the revocation section of the Johnston Health Authorization To Disclose Health Information Form.
1. You have the right to request restrictions on our uses and disclosures of protected health information for treatment, payment and health care operations. However, we are not required to agree to your request except as outlined below. If you would like to request a restriction on our uses and disclosures of your protected health information, please complete the appropriate section of the Johnston Health Privacy Request Form. This form is available from any registration area, nursing unit, the Patient Services Office or the Privacy Officer. Approved restrictions are binding for all future visits to our facility, unless an expiration date or event is contained in the restriction request or if the patient revokes the restriction in writing. Revocation of a restriction should be requested on the Johnston Health Privacy Request Revocation Form.
2. You have the right to request restrictions on our disclosure of protected health information to your health plan for services or items paid out-of-pocket in full. We are required to comply with this request. If you would like to request a restriction on our disclosures of your protected health information to your health plan for services and items paid out-of-pocket in full, please complete the appropriate section of the Johnston Health Privacy Request Form.
3. You have the right to reasonably request to receive communications of protected health information by alternative means or at alternative locations. If you would like to request alternative communications please complete the appropriate section of the Johnston Health Privacy Request Form. This form is available from any registration area, nursing staff, the Patient Services Office or the Privacy Officer. Approved requests for alternative communications are binding unless an expiration date or event is contained in the request or if the patient revokes the request in writing. Revocation of a request should be made on the Johnston Health Privacy Request Revocation Form.
4. Subject to payment of a reasonable copying charge, you have the right to inspect and copy the protected health information contained in your medical and billing records and in any records used by us to make decisions about you, except for:
(i) psychotherapy notes, which are notes recorded by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session and that have been separated from the rest of your medical record;
(ii) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
(iii) protected health information involving laboratory tests when your access is required by law;
(iv) if you are a prison inmate and obtaining such information would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, or the safety of any officer, employee, or other person at the correctional institution or person responsible for transporting you;
(v) if we obtained or created protected health information as part of a research study for as long as the research is in progress, provided that you agreed to the temporary denial of access when consenting to participate in the research;
(vi) your protected health information is contained in records kept by a federal agency or contractor when your access is required by law. If you cannot afford to pay for copies, you will not be denied access; or
(vii) if the protected health information was obtained from someone other than us under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.
5. We may deny a request for access to protected health information if:
(i) a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger your life or physical safety or that of another person;
(ii) the protected health information makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person; or
(iii) the request for access is made by the individual’s personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to you or another person.
If we deny a request for access for any of the three reasons described above, then you have the right to have our denial reviewed in accordance with the requirements of applicable law.
6. You have the right to request a correction to your protected health information, but we may deny your request for correction, if we determine that the protected health information or record that is the subject of the request:
(i) was not created by us, unless you provide a reasonable basis to believe that the originator of protected health information is no longer available to act on the requested amendment;
(ii) is not part of your medical or billing records;
(iii) is not available for inspection as set forth above; or
(iv) is accurate and complete.
In any event, any agreed upon correction will be included as an addition to, and not a replacement of, already existing records. If you would like to request a correction of your protected health information, please complete the Johnston Health Request For Access to Health Information.
7. You have the right to receive an accounting of disclosures of protected health information made by us to individuals or entities other than to you, except for disclosures for our own uses for treatment, payment and health care operations, (as those functions are described above) and with certain other exceptions pursuant to the law. If you would like to request an accounting of disclosures, please complete the Johnston Health Request for Access to Health Information.
8. You have the right to request and receive a paper copy of this notice from us.
9. You have the right to be notified in the event of a breach of your unsecured protected health information.
If you believe that your privacy rights have been violated, you should immediately contact Johnston Health’s Privacy Officer at 919-938-7121. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of Health and Human Services.