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Patient Rights & Responsibilities

HIPAA

Effective: September 23, 2013

The HIPAA Privacy Rule (HIPAA) gives you the right to be informed of the privacy practices of the Hospital & Medical Foundation of Paris, Inc. (HMFP) and its affiliates and subsidiaries, as well as the right to be informed of your privacy rights with respect to your protected health information (PHI). HMFP uses health information for the treatment of patients, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive.

We are committed to protecting the privacy of your PHI and only using and disclosing your PHI as necessary to provide you with health care services. This Notice has been created to help you understand our legal duties to protect your PHI by describing how HMFP will use and disclose your PHI. If you have any questions about this notice, please contact HMFP’s Privacy Officer at (217) 466-4030.

What is protected health information?

Protected Health Information (PHI) is any health care related information we might have about you, whether in paper, electronic, or other format, from which your identity might be known. Some examples of PHI are:

  • medical records, including but not limited to, doctors’ notes and orders, X-ray films and reports, lab reports, nurses’ notes, and ambulance run reports;
  • demographic information, such as your name, address, telephone number, date of birth, and religious affiliation; and
  • billing and payment information, such as the name of your health insurer.

Who will follow this notice?

This notice describes HMFP’s practices relating to your PHI. In addition to treatment, payment, and health care operation purposes, we may share PHI for the joint management and operation of these entities. This sharing does not mean that one organization is responsible for the activities of another, but rather that we are all committed to protecting our patients’ privacy rights.

In this notice, HMFP includes:

  • the affiliates listed above;
  • our hospitals’ Medical Staff;
  • independent contractors, such as consultants; and
  • all employees, staff, volunteers and students of each of these HMFP’s affiliates.

Our pledge regarding medical information

We are required by law to create and maintain medical records, charts, and files of the care and services you receive at HMFP. We use this information to provide quality care to our patients. We understand that your health and medical care are personal and we are committed to protecting the PHI we maintain about you. This Notice applies to your entire PHI at HMFP. This Notice will tell you about the ways we may use and disclose your PHI, and will describe your rights and certain obligations we have regarding the use and disclosure of your PHI.

We are required by law to:

  • make sure your PHI is kept private and notify you after a breach of your unsecured PHI;
  • provide this Notice of our legal duties and privacy practices; and
  • follow the terms of this Notice.

We are also required by federal law to follow Illinois laws that may provide you with more rights or greater protections relating to your PHI.

How will we use and disclose your PHI?

The following categories summarize different ways that we may use and disclose PHI. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. Any type of use or disclosure of your PHI not described in a category included in this Notice will require your written authorization before it is made.

  • For Treatment--We may use and disclose your PHI to provide medical treatment or services to you. We may disclose health information about you to doctors, therapists, technicians, office staff, or other personnel who are involved in your care, whether at HMFP or at another office or facility.

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. We may need to share PHI between the HMFP entities or with other health care providers in order to ensure that you get the health care services you need.

  • Individuals Assisting with Your Care or Payment--We may disclose your PHI to people involved in your care, such as family members, friends, or clergy, or to family or other individuals who are assisting you with payment of your bills. We may also disclose PHI to a parent or legal guardian, if the services we provide are for a child or an incompetent adult.
  • For Payment--We may use and disclose information about you so that the treatment and services you receive from us may be billed to your insurance company or to another individual or entity responsible for or assisting with payment of your bills.

For example, we may disclose PHI regarding a service you received from us so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a service you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment. We may also disclose your PHI to a third-party payer who is conducting an audit related to the payment of your claims. For example, if your insurance company conducts an audit to verify our charges, we may provide that company with copies of claim forms, doctors’ orders, and other records documenting your receipt of all services we billed. We must agree to a request by you to restrict certain disclosures of your PHI to a health plan when you pay for a service or item out of pocket in full.

  • Workers’ Compensation--We may disclose your PHI for workers’ compensation purposes if you have a work-related injury or illness. Such disclosures will be made consistent with applicable state workers’ compensation laws.
  • For Health Care Operations--We may use and disclose your PHI for our internal business operations. These uses and disclosures help us to ensure HMFP provides quality care and services to our patients. We may use your PHI along with PHI of other HMFP patients to assess and improve our operations. Examples of how we may use and disclose our patients’ PHI for our internal operations include:
    • to review our treatment and services, and to evaluate the performance of our staff in caring for you;
    • to decide what additional services HMFP might offer, what services are not needed, and whether certain treatments are effective;
    • to provide you with general information about HMFP and our services in newsletters and other communications;
    • for business management and general administrative activities;
    • for our licensing and accreditation activities;
    • for teaching purposes and to provide training to doctors, nurses, technicians, medical students, and others involved in authorized training programs;
    • to compare our services with the services of other health care providers to see where we can make improvements in the care we provide; and
    • to other health care providers who also have a treatment relationship with our patients for the quality assessment and improvement activities of the other health care provider.
  • Business Associates--We may disclose PHI to our business associates to enable them to perform services for us or on our behalf relating to our operations. Some examples of business associates are our auditors, accrediting agencies, consultants, and billing and collections companies. Our business associates are required to maintain the same high standards of safeguarding your privacy that we require of our own employees and affiliates.
  • Facility Directories--If you are admitted to HMFP, we may list PHI about you in our facility directory, including your name, location in the facility, and general condition. We will only disclose this information to individuals who ask for you by full name. If you provide it, we will also list your religious affiliation, but will only disclose this information to members of the clergy. If you ask, we will not disclose the facility directory information to the public.
  • Fund Raising--We may use and disclose your PHI to contact you to raise funds for HMFP, which are used to support our mission of providing health care services to the communities we serve. If you do not wish to be contacted regarding fundraising, you will have the opportunity to have your name removed from our mailing list.
  • Research--Under certain circumstances, we may use and disclose PHI 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 are governed by federal rules, and are subject to a special approval process before the research begins. This process evaluates the benefits of a proposed research project and its use of PHI, trying to balance the research needs with patients’ need for privacy of their medical information.
  • Other Uses and Disclosures--As part of our treatment, payment and health care operations, we may also use and disclose your PHI for the following purposes:
    • to remind you of an appointment;
    • to inform you of potential treatment alternatives or options; and
    • to inform you of health-related benefits or services that may be of interest to you
  • Uses and Disclosures Requiring Authorization--Most uses and disclosures of psychotherapy notes will require authorization. “Psychotherapy notes” are the private notes of mental health professionals that are kept separately from the record. Uses and disclosures of PHI for marketing purposes and any disclosure that constitutes the sale of PHI will also require authorization.

Special situations

As Required By Law

We will disclose your PHI to authorities when required to do so by federal, state, or local law. Examples of these requirements include the following: 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; in mandatory reporting situations, including when there is reason to suspect domestic, child, or elder abuse or neglect; about a death we believe may be the result of criminal conduct; about criminal conduct at a HMFP facility; 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.

For Public Health or Safety

We may use and disclose PHI when required to do so for public health activities, or as necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. For example, we will disclose PHI to report births and deaths to the Department of Public Health. We may also disclose PHI to report, prevent, or control disease, injury, or disability.

Health Oversight Activities

We may disclose your PHI to a health oversight agency for activities authorized by law. Examples of these oversight activities include:

  • medical device tracking, product tracking, and drug or product recalls, all of which are required by the federal Food and Drug Administration (FDA);
  • disclosures required by Medicare or Medicaid, or another state or federal agency or oversight board to audit, investigate, inspect, or conduct other activities, which may be necessary for the government to monitor specific governmental programs; and
  • disclosures required by the Secretary of the Department of Health and Human Services (HHS) to investigate or determine our compliance with the federal privacy law.

Coroners, Medical Examiners and Funeral Directors We may disclose PHI 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 PHI about HMFP patients to funeral directors as necessary to carry out their duties.