Effective
Date:
This notice describes how protected health information (personal information
and medical information) about you may be used and disclosed and how you can
get access to this information.
PLEASE REVIEW CAREFULLY.
Patients: If you have
any questions about this notice, contact the Chief Privacy Officer of Sparks
Health System. Sparks Health System includes Sparks Regional Medical Center,
Sparks Medical Foundation, Sparks Development Foundation, Sparks Management
Services Organization, Charleston Rural Health Clinic and Sparks PremierCare.
Who will
follow this notice:
This notice describes Sparks Health System's practices and that of: Any health
care professional authorized to review and/or enter information into your
medical record. All departments, nursing units and clinics of Sparks Health
System. Any member of a volunteer group we allow to help you while you are in
Sparks Health System. All employees, staff and other Sparks Health System
personnel.
Sparks
Health System (SHS), its medical and dental staff and others providing care or
ordering tests at SHS are part of a clinically integrated care setting that
constitutes an organized health care arrangement under the Health Insurance
Portability and Accountability Act (HIPAA). This arrangement involves
participation of legally separate entities in which no entity will be responsible
for the medical judgment or patient care provided by the other entities in the
arrangement. Sharing information allows us to enhance the delivery of quality
care to our patients. All entities, however, have agreed to abide by the Notice
of Privacy Practices (NPP) while working within SHS settings.
You may
receive another NPP from physicians and other health care providers upon your
first encounter in their office, which may be different from this NPP and which
will govern the protected health information (PHI) maintained by that provider.
These physicians and health care providers will be able to access, use and
disclose your PHI to carry out treatment, payment or health business
operations.
Some new
terms you may hear and their definitions are:
Protected
Health Information or PHI: information we use to render care to you and bill
for services provided.
Privacy Officer: the individual at SHS who has
responsibility for developing and implementing all policies and procedures
concerning your PHI and receiving and investigating any complaints you may have
about the use and disclosure of your PHI.
Business Associate: an individual or
business that works with SHS.
Organized Health Care Arrangement (OHCA): SHS and
the independent health care professionals who are part of a clinically
integrated care setting in which your PHI will be shared for purposes of
treatment, payment, and health care operations as described below. This means
that the individuals who provide care for you while you are at SHS will share information.
Our pledge
regarding protected health information (PHI)
We
understand that PHI about you and your health is personal. We are committed to
protecting PHI about you. We create a record of the care and services you
receive at SHS. We need this record to provide you with quality care and to
comply with certain legal requirements. This notice applies to all of the
records of your care generated by SHS, whether made by SHS personnel or your
personal doctor. Your personal doctor may have different policies or notices
regarding his/her use and disclosure of your PHI created in the office or
clinic.
This notice
will describe the ways in which we may use and disclose PHI about you. We also
describe your rights and certain obligations we have regarding the use and
disclosure of PHI.
We are
required by law to:
Make sure that PHI that identifies you is kept private. Give you this notice of
our legal duties and privacy practices with respect to PHI about you. Follow
the terms of the notice that is currently in effect.
How we may
use and disclose PHI about you
The
following categories describe different ways that we use and disclose PHI. For
each category of uses or disclosures, we will explain what we mean and try to
give some examples. 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. The examples included with each category do
not list every type of use or disclosure that may fall within that category.
1.
Treatment. We may use PHI about you to coordinate or manage your health care
and related services. We may disclose PHI about you to doctors, nurses,
technicians, medical and other health students or other personnel who are
involved in taking care of you. 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. Different departments of SHS may also share PHI
about you in order to coordinate the different things you need, such as
prescriptions, lab work and x-rays. We also may disclose PHI about you to
people outside SHS who may be involved in your medical care after you leave
SHS, such as family members, clergy or others we use to provide services that
are part of your care.
2. Payment.
We may use and disclose PHI about you so that the treatment and services you
receive at SHS may be billed to and payment may be collected from you, an
insurance company or a third party. For example, we may need to give your
health plan carrier information about surgery you received at SHS so that your
health plan will pay us or reimburse you for the surgery.
We may also
tell your health plan about a treatment you are going to receive to obtain
prior approval or to determine whether your plan will cover the treatment.
We may also
disclose PHI to another health care provider or to a company or health plan
required to comply with the HIPAA Privacy Rule for the payment activities of
that health care provider, company, or health plan. For example, we may allow a
health insurance company to review PHI for the insurance company's activities
to determine insurance benefits to be paid for your care.
3. Health
Care Operations. We may use and disclose PHI about you in performing business
activities, which are called health care operations. These uses and disclosures
are necessary to run SHS and allow us to improve the quality of care we provide
and to reduce health care costs. For example, we may use PHI to review our
treatment and services and to evaluate the performance of our staff in caring
for you, such as patient satisfaction surveys and review by Administration.
We may also combine
PHI about many SHS patients to decide what additional services SHS should
offer, what services are not needed, and whether certain new treatments are
effective.
We may also disclose information to doctors, nurses, technicians,
medical students, and other SHS personnel for review and learning purposes. We
may also combine the PHI we have with PHI from other health systems to compare
how we are doing and see where we can make improvements in the care and
services we offer. We may remove information that identifies you from this set
of PHI so that others may use it to study health care and health care delivery
without learning who the specific patients are.
If another
health care provider, company, or health plan that is required to comply with
the HIPAA Privacy Rule has or once had a relationship with you, we may disclose
PHI about you for certain health care operations of that health care provider
or company. For example, such health care operations may include: reviewing and
improving the quality, efficiency and cost of care provided to you; reviewing
and evaluating the skills, qualifications and performance of health care
providers; providing training programs for students, trainees, health care
providers, or non-health care professionals; cooperating with outside
organizations that evaluate, certify, or license health care providers or staff
in a particular field or specialty; and assisting with legal compliance
activities of that health care provider or company.
4. Business
Associates. We may disclose your PHI to business associates. We will only make
these disclosures if we have received satisfactory assurance that the Business
Associate will properly safeguard your privacy and the confidentiality of your
PHI. For example, we may contract with a company outside of SHS to provide
medical transcription services for us, or to provide collection services for
past due accounts.
5.
Appointment Reminders. We may use and disclose PHI to contact you as a reminder
that you have an appointment for treatment or medical care at SHS.
6. Treatment
Alternatives. We may use and disclose PHI to tell
you about or recommend possible treatment options or alternatives that may be
of interest to you.
7.
Health-Related Benefits and Services. We may use and disclose PHI to tell you
about health-related benefits or services that may be of interest to you.
8.
Fund-raising Activities. We may use PHI about you to contact you in an effort
to raise money for SHS and its operations. We may disclose PHI to a foundation
related to SHS so that the foundation may contact you in raising money for SHS.
We only would release contact information, such as your name, address and phone
number and the dates you received treatment or services at SHS. If you do not
want SHS to contact you for fund-raising efforts, you must notify the Chief
Privacy Officer in writing.
9. Hospital
Directory. We may include certain limited information about you in the hospital
directory while you are a patient at the hospital. This information may include
your name and location in the hospital. The directory information may be
released to people who ask for you by name. Clergy members of your denomination
may also be provided this information.
10.
Individuals Involved in Your Care or Payment for Your Care. We may release PHI
about you to a friend or family member who is involved in your medical care. We
may also tell your family or friends your condition and that you are in SHS. We
may also disclose PHI about you to an entity assisting in a disaster relief
effort so that your family can be notified about your condition, status and
location.
11.
Research. Under certain circumstances, we may use and disclose PHI 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 PHI, trying to balance the research needs with
patients' need for privacy of their PHI.
Before we
use or disclose PHI for research, the project will have been approved through
this research approval process; we may, however, disclose PHI 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 PHI they review does
not leave SHS. 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 SHS.
12. As
Required By Law. We will disclose PHI about you when required to do so by
federal, state or local law. For example, Arkansas law requires us to report
all births and deaths that occur in the hospital to the Arkansas Department of
Health.
13. To Avert
a Serious Threat to Health or Safety. We may use and disclose PHI about you
when necessary to prevent a serious threat to your health and safety or the
health and safety of the public or another person. Any disclosure, however,
would only be to someone able to help prevent the threat.
14. Organ
and Tissue Donation. We will release PHI to organizations that handle organ
procurement or organ, eye or tissue transplantation or to an organ donation
bank, as necessary to facilitate organ or tissue donation and transplantation.
15. Military
and Veterans. If you are a member of the armed forces, we may release PHI about
you as required by military command authorities. We may also release PHI about
foreign military personnel to the appropriate foreign military authority.
16. Workers'
Compensation. We may release PHI about you for workers' compensation or similar
programs. These programs provide benefits for work-related injuries or illness.
17. Public
Health Risks. We may disclose PHI about you for public health activities, to,
for example:
- Prevent or
control disease, injury or disability.
- Report birth defects or spinal cord injuries.
- Report cancer diagnoses and tumors.
- Report child abuse or neglect.
Report reactions to medications or problems with products.
- Notify people of recalls of products they may be using.
- Notify a person who may have been exposed to a disease or may be at risk for contracting
or spreading a disease or condition.
- 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.
18. Health
Oversight Activities. We may disclose PHI to a health oversight agency for
activities necessary for the government to monitor the health care system,
government programs, and compliance with applicable laws. These oversight
activities include, for example, audits, investigations, inspections, medical
device reporting and licensure.
19. Lawsuits
and Disputes. If you are involved in a lawsuit or a dispute, we may disclose
PHI about you in response to a court or administrative order. We may also
disclose PHI about you in response to a court-ordered subpoena, discovery
request, or other lawful process by someone else involved in the dispute, but
only if efforts have been made to tell you about the request or to obtain an
order protecting the information requested.
20. Law
Enforcement. We may release PHI if asked to do so by a law enforcement
official:
- In response
to a court order, court-ordered 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.
- About criminal conduct at SHS.
- 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.
21.
Coroners, Medical Examiners and Funeral Directors. We may release PHI to a
coroner or medical examiner, when requested to do so in writing. This may be
necessary, for example, to identify
a deceased person or determine the cause of death. We may also release PHI
about patients of SHS to funeral directors as necessary to carry out their
duties.
22. National
Security and Intelligence Activities. We may release PHI about you to
authorized federal officials for intelligence, counterintelligence, and other
national security activities authorized by law.
23.
Protective Services for the President and Others. We may disclose PHI about you
to authorized federal officials so they may provide protection to the
President, other authorized persons or foreign heads of state or conduct
special investigations.
24. Inmates.
If you are an inmate of a correctional institution or under the custody of a
law enforcement official, we may release PHI about you to the correctional
institution or law enforcement official. This release would be necessary (1)
for the institution to provide you with health care; (2) to protect your health
and safety or the health and safety of others; or (3) for the safety and
security of the correctional institution.
Your rights
regarding PHI about you
Under
federal law, you have the following rights regarding PHI we maintain about you:
1. Right to
Inspect and Copy. You have the right to request the opportunity to inspect and
receive a copy of PHI that may be used to make decisions about your care.
Usually, this includes medical and billing records, but does not include
psychotherapy notes or information gathered or prepared for a civil, criminal,
or administrative proceeding.
To inspect
and copy PHI that may be used to make decisions about you, you must submit your
request in writing to the Medical Record Department of the facility where the
treatment was rendered. If you request a copy of the information, we will
charge a fee for the costs of copying, postage, labor, and supplies associated
with your request.
We may deny
your request to inspect and copy in certain very limited circumstances. If you
are denied access to PHI, you may request that the denial be reviewed. Another
licensed health care professional chosen by SHS will review your request and
the denial. The person conducting the review will not be the person who denied
your request. We will comply with the outcome of the review.
2. Right to
Amend. If you feel that the PHI we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the right to request an
amendment for as long as the information is kept by or for SHS. To request an
amendment, your request must be made in writing and submitted to the Chief
Privacy Officer. In addition, you must provide a reason that supports your
request. We may deny your request for an amendment if it is not in writing or
does not include a reason to support the request. In addition, we may deny your
request if you ask us to amend information that:
- Was not
created by us, unless the person or entity that created the information is no
longer available to make the amendment.
- Is not part of the PHI kept by or for SHS.
- Is not part of the information that you would be permitted to inspect and copy.
- Is accurate and complete.
If your
request to amend is denied, you have the right to appeal that decision. An ad
hoc committee comprised of the Chief Privacy Officer, Director of Medical
Records, Quality/Risk Management, Nursing, and a physician will hear appeals in
a timely manner. We will comply with the outcome of the review.
3. Right to
Receive an Accounting of Disclosures. You have the right to request an
accounting of certain disclosures that we have made of PHI about you. This is a
list of the disclosures made by us during a specified period of up to six years
other than disclosures made for treatment, payment and health care operations.
To request
this list or accounting of disclosures, you must submit your request in writing
to the Chief Privacy Officer. Your request must state a time period that may
not be longer than six years and may not include dates before April 14, 2003.
Your request should indicate in what form you want the list (for example, on
paper, electronically). The first list you request within a 12-month period
will be free. For additional lists, we may charge you for the cost involved,
and you may choose to withdraw or modify your request at that time before any
costs are incurred.
4. Right to
Request Restrictions. You have the right to request a restriction or limitation
on the PHI we use or disclose about you for treatment, payment or health care
operations. You also have the right to request a limit on the PHI we disclose
about you to someone who is involved in your care or the payment for your care,
like a family member or friend. For example, you could ask that we not use or
disclose information about a surgery you had.
We are not
required to agree to your request. If we do agree, we will comply with your
request unless the information is needed to provide you emergency treatment.
To request
restrictions:
- If you have left the facility, you must make your request in writing to the
Director of Medical Records or the Chief Privacy Officer.
- If you are in the process of being admitted, you may make your request to the
registration staff.
- If you are currently hospitalized, you may make your request to the Nursing Coordinator.
- If you are checking-in at a physician office, the receptionists at SHS clinics
will assist you with your request.
In your
request, you must tell us:
(1) what information you want to limit;
(2) whether
you want to limit our use, disclosure or both; and
(3) to whom you want the
limits to apply, for example, disclosures to your spouse.
5. Right to
Request Confidential Communications. You have the right to request that we
communicate with you about your PHI in a certain way or at a certain location.
For example, you can ask that we only contact you at work or by mail.
To request
confidential communications, you must make your request in writing to the Chief
Privacy Officer. We will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must specify how or where you
wish to be contacted.
6. Right to
a Paper Copy of This Notice. You have the right to receive a paper copy of this
notice. You may obtain a copy of this notice at our web site: www.sparks.org.
To obtain a paper copy of this notice, contact Patient Registration or the
clinic receptionist.
Changes to
this notice
We reserve
the right to change this notice. We reserve the right to make the revised or
changed notice effective for PHI we already have about you as well as any
information we receive in the future. We will post a copy of the current notice
in the hospital and clinics of SHS. The notice will contain on the first page,
in the top right-hand corner, the effective date. In addition, each time you
register as a patient within SHS, we will offer you a copy of the current
notice in effect.
Other uses
of PHI
Other uses
and disclosures of PHI not covered by this notice or the laws that apply to us
will be made only with your written permission. If you provide us permission to
use or disclose PHI about you, you may revoke that permission, in writing, at
any time. If you revoke your permission, we will no longer use or disclose PHI
about you for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already made with your
permission, and that we are required to retain our records of the care that we
provided to you.
PHI
complaints
If you
believe your privacy rights have been violated, you may file a complaint with
SHS or with the Secretary of the Department of Health and Human Services.
To file a
complaint with SHS, write:
Chief Privacy Officer
Sparks Health System
P.O. Box 17006
Fort Smith, AR 72917-7006
privacy@sparks.org
To file a
complaint with the Secretary of the Department of Health and Human Services,
contact:
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
HHS.Mail@hhs.gov
The
complaint to the Secretary must be filed within 180 days of when the
complainant knew or should have known that the act or omission complained or
occurred. The complaint must be in writing, either on paper or electronically,
name the entity that is the subject of the complaint and describe the acts or
omissions believed to be in violation of the standards.
You will not
be penalized for filing a complaint.
This
document is Sparks Health System's Notice of Privacy Practices. You will be
asked to sign a separate form acknowledging that you have received this copy of
Sparks Health System's Notice of Privacy Practices. If you have any questions
about Sparks Health System's Notice of Privacy Practices, please feel free to
contact the Chief Privacy Officer at (479) 441-5259.