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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.
I. Who We Are. This Notice describes the privacy practices of Eagleville Foundation, their physicians, residents, nurses, therapists, case managers, volunteers and other personnel (collectively, “Eagleville”). It applies to services furnished to you at any of our locations covered by this Notice.
Our Privacy Obligation.
We are required by law to maintain the privacy of your health
information (“Protected Health Information” or “PHI”) and to provide you
with this Notice of our legal duties and privacy practices with respect
to your Protected Health Information.
When we use or disclose your Protected Health Information, we are
required to abide by the terms of this Notice (or other notice in effect
at the time of the use or disclosure).
Federal and State law and
regulations protect the confidentiality of alcohol and drug abuse patient
records maintained by us (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for
Federal Laws; 42 CFR Part 2 for Federal Regulations; 71 PS § 1690.108 for
State Law and 4 PA Code § 255.1 et seq. 28 PA Code Chapters 701, 709,
711, 713 for State Regulations).
Additional State laws and regulations protect HIV/AIDS-related information
and mental health information.
They are more restrictive then the Health Insurance Portability and
Accountability Act (“HIPAA”).
III. Uses and Disclosures Without Your Written Authorization
1. Substance Abuse Information: Generally, we may not disclose to persons outside our facilities that a patient is being or has been treated at our facilities, or disclose any PHI about a patient or identifying a patient as an alcohol or drug abuser, unless (1) the disclosure is allowed by court order, (2) the disclosure is made to medical personnel in a medical emergency, (3) the disclosure is made to the patient or representative, at his or her request, or (4) the disclosure is made to the Secretary of the Department of Health and Human Services to investigate our compliance with HIPAA.
Public Health Activities: We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; and (2) to report information about suspected child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports.
2. Use Within Eagleville:
a. For Treatment. We may use health information about you to provide you with medical treatment. We may share health information about you with doctors, nurses, therapists or other Eagleville Personnel who are involved in taking care of you, or provide services to you at Eagleville. Different departments of Eagleville also may share health information about you in order to coordinate your care and provide you medication, lab work and x-rays.
b. For Payment. We may use health information about you so that the
treatment and services you receive at Eagleville may be billed to you, an
insurance company or a third party. For example, our billing department will
use your health information to prepare
however we will obtain your permission before disclosing your PHI to an
outside party such as an insurance company.
For Healthcare Operations.
We may use your
PHI for our health care operations, which include internal administration
and planning and various activities that improve the quality and cost
effectiveness of the care that we deliver to you.
For example, we may use PHI to evaluate the quality and competence of
our physicians, nurses and other health care workers.
We may use PHI for our patient satisfaction survey process.
We will limit our use of your PHI to the minimum amount necessary to
achieve a permissible purpose.
3. Geriatric Psychiatry Patients: We may disclose limited health information pertaining to patients in our geriatric psychiatry program who are not receiving substance abuse treatment in a few additional circumstances, including to those engaged in providing treatment for the person; the county mental health administrator; a court or mental health review officer in connection with commitment proceedings; reviewers and inspectors for purposes of obtaining certification as an eligible provider of services; persons participating in utilization review; appropriate personnel in connection with child or patient abuse; attorneys assigned to represent the subject of a commitment hearing; in response to a medical emergency situation when release of information is necessary to prevent serious risk of bodily harm or death; and to third party payors. Written authorization will not be required for these disclosures.
4. Other Permissible Uses and Disclosures
a. HIV Disclosure: Our physicians may disclose confidential HIV-related information without written authorization if all of the following conditions are met: (1) the disclosure is made to a known contact of the subject; (2) the physician reasonably believes disclosure is medically appropriate, and there is a significant risk of future infection to the contact; (3) the physician has counseled the subject regarding the need to notify the contact, and the physician reasonably believes the subject will not inform the contact or abstain from sexual or needle-sharing behavior which poses a significant risk of infection to the contact; and (4) the physician has informed the subject of his intent to make such disclosure. When making such disclosure to a contact, the physician shall not disclose the identity of the subject or any other contact. Disclosure shall be made in person except where circumstances reasonably prevent doing so. A physician shall have no duty to identify, locate or notify any contact, and no cause of action shall arise for nondisclosure or for disclosure in conformity with this section. Eagleville may also disclose HIV-related information, in certain limited circumstances, to the victim of a rape, sexual assault, or other sexual offense.
b. Treatment Alternatives: We may use health information to tell you about possible treatment options or alternatives that may be of interest to you.
c. Health-Related Benefits and Services and Reminders: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
d. Fundraising Activities: We may use health information to contact you in an effort to raise money as part of a fundraising effort. We will only use contact information, such as your name, address and phone number and the dates you received treatment or services at Eagleville.
If you do not wish us to contact you for fundraising activities you may opt
out of these contacts, or if you wish to opt back into the contacts, you
must notify us in writing.
e. As Required by Law: We will disclose health information about you when required to do so by federal, state or local law.
IV. Uses and Disclosures Requiring Your Written Authorization
Use or Disclosure with Your Authorization: For any purpose other than the ones described above, we may only use or disclose your PHI when you grant us your written authorization on a release form that is in compliance with the Federal and State law and regulations. Even with your written authorization, State law applicable to drug and alcohol treatment providers limits our ability to make certain disclosures.
Qualified Service Organizations: Eagleville contracts with qualified
service organizations (providing data processing, bill collecting,
laboratory analyses, legal, medical, accounting, or other professional
services) as necessary for its operation and provision of services.
Each qualified service organization agrees in writing to abide by the
same privacy and confidentiality obligations that apply to Eagleville under
HIPAA and applicable Federal and State laws and regulations.
When you authorize us to use your PHI for medical treatment or to
obtain insurance eligibility or benefits, you are also authorizing
Eagleville’s disclosure to the necessary qualified service organizations.
V. Your Rights Regarding Your Protected Health Information
1. For Further Information; Complaints: If you desire
further information about your privacy rights, are concerned that we have
violated your privacy rights or disagree with a decision that we made about
access to your PHI, you may contact our Privacy Officer at the address provided in this Notice. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, NY 10278. Also upon request, the Privacy Official can provide you with the additional contact information for the Director. We will not retaliate against you if you file a complaint with the Director or us.
2. Right to Receive Confidential Communications: You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations. If you wish to make a request, please contact our Privacy Official in writing.
3. Right to Revoke Your Authorization: You may revoke any of your authorizations except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Official identified below.
4. Right to Inspect and Copy Your Health Information: You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records
in through a written request to the Privacy Officer. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Medical Records Department and submit the completed form to the Privacy Officer. If you request copies, we will charge you in accordance with Pennsylvania law. If you are denied access, you may request that the denial be
reviewed. You have a right to request an electronic copy of your record in a form and format that is readily producible by us. If we can not agree upon a readily producible format, we will provide you with a paper copy.
5. Right to Amend Your Records: You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Medical Records Department and submit the completed form to the Privacy
Officer. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
6. Right to Receive An Accounting of Disclosures: Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. The accounting will not include disclosures to you or disclosures pursuant to an authorization you have provided. If you request an accounting more than once during a twelve (12) month period, we will charge you $1.00 per page for the accounting statement. We will also charge you for our postage costs, if you request that we mail the copies to you.
7. Right to Request Restrictions: You have the right to
request a restriction or limitation on the health information about you that we
use or disclose about you. Your request must be in writing. Please be aware that
we are not required to agree to your request for restrictions. If we agree to
your request for a restriction, we will comply with it unless the information is
needed for emergency treatment. Effective September 23, 2013 (or such other date
specified as the effective date under applicable law), we will comply with any
restriction request: (1) except as otherwise required by law, the disclosure is
to the health plan for purposes of carrying out payment or health care
operations (and is not for purposes of carrying out treatment); and (2) the
protected health information pertains solely to a health care item or service
for which the health care provider involved has been paid out-of-pocket in full.
To request restrictions, you must make your request in writing to the
Privacy Officer. 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
8. Right to Receive a Paper Copy of this Notice: Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
9. Drug and Alcohol Abuse Information: The confidentiality of alcohol and drug abuse patient records maintained by Eagleville is protected by Federal and State law and regulations. Generally, Eagleville may not say to a person outside Eagleville that a patient is being treated by Eagleville or disclose any information identifying a patient as an alcohol or drug abuser unless: (1) the patient consents in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency. Violation of the Federal law and regulations is a crime. Suspected violations may be reported to appropriate authorities in accordance with government regulations. Federal and State law does not protect information about suspected child abuse or neglect from being reported to appropriate authorities. Federal and State law prohibits further disclosure of this information without express written consent of the person to whom it pertains, or as otherwise permitted by applicable regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose. State and Federal law restricts the use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.
10. HIV Information: If PHI pertaining to HIV has been disclosed, Pennsylvania law prohibits the recipient from making any further disclosure of the information unless expressly permitted by your written consent or is authorized by the Confidentiality of HIV-Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose. (35 P.S. § 7601 et. seq.)
11. Right to be informed of a Breach of your
PHI: In the event that there is an improper use, access of
disclosure of your PHI you have the right to be informed of the Breach by
VI. Effective Date and Duration of This Notice
1. Effective Date: This Notice is effective on
September 23, 2013.
2. Right to Change Terms of this Notice: We may change
the terms of this Notice at any time. If we change this Notice, we may make the
new notice terms effective for all Protected Health Information that we
maintain, including any information created or received prior to issuing the new
notice. If we change this Notice, we will post the new notice in our waiting
areas and on our Internet site at www.eaglevillehospital.org. You also may
obtain any new notice by contacting the Privacy Officer.
VII. Privacy Officer
You may contact the Privacy Officer at:
Julia LawsonE-mail: email@example.com
100 Eagleville Road,
P.O. Box 45
Eagleville, PA 19408
Telephone Number: (610) 635-7457