Effective Date: April 14, 2003

 

This notice describes how medical information about you may be used and disclosed and how you get access to this information.

Please review it carefully.

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Our Pledge Regarding your Medical Information

We understand that your medical information is personal; therefore, we are committed to protecting your medical information in accordance with applicable laws and accreditation standards regarding patient privacy. As a patient at Dorminy Medical Center, the medical treatment you receive is recorded in a medical record. In order to provide you with comprehensive quality health care, we share your medical record with health care providers involved in your care. We also use your medical information, to the extent necessary, to conduct our operations, to collect payment for services and to comply with the laws that govern health care. We will not use or disclose your medical information for any other purposes without your permission.

This Notice describes your rights and certain obligations we have regarding the use and disclosure of medical information. This Notice also tells you about the ways in which we may use or disclose medical information about you.

Applicable federal and Georgia law requires us to:

§        make sure that medical information that identifies you is kept private;

§        give you this Notice of Privacy Practices (Notice) describing our privacy practices and legal duties; and

§        follow the terms of this Notice that is currently in effect.

Your Rights Regarding your Medical Information

You have the following rights regarding the medical information we maintain about you.

Right to Inspect and Request a copy of your Medical Record. You have the right to inspect and request a copy of your medical information as long as the information is kept by our hospital. This includes medical and billing records but may not include some records such as psychotherapy notes in some circumstances. To inspect and have your medical information copied, please submit your written request on a form that will be provided to you upon your request. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other expenses associated with your request.

Under certain limited circumstances, we may deny your request to inspect and obtain a copy of your medical information. If you are denied access, you may request that the denial be reviewed. Another unbiased licensed health care professional, chosen by our facility, will review your request and the denial. We will comply with the outcome of the review. 

Right to Amend your Medical Information. If you believe that the medical information we have about you is incorrect or incomplete, you may ask us to amend it. You have the right to amend your medical information as long as the information is kept by our health system. To amend your medical information, please submit your written request on a form that will be provided to you upon your request.

We may deny your request for an amendment if it is not in writing or it does not include a reason to support the request. We also 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 medical information kept by or for our facility;

§          is not part of the information which you would be permitted to inspect and copy; or

§           is accurate and complete.

If we deny part or your entire request, we will provide a written explanation

Right to an Accounting of Disclosures of your Medical Information. You have a right to receive an “accounting of disclosures.” This is a list of certain disclosures we made of your medical information. To request an accounting of disclosures of your medical information, please submit your written request on a form that will be provided to you, upon your request. 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 costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restriction. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. We are not required to agree to your request for a restriction. However, if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time.

To request a restriction, please submit your written request on a form that will be provided to you upon 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.

Right to Request Confidential Communications. You have the right to request that we communicate with you about your medical information by alternative means or to an alternative location. For example, you may ask that we contact you at home instead of at work. We will not ask you the reason for your request and we will try to accommodate all reasonable requests. To request confidential communications, please submit your written request on a form that will be provided to you upon your request.

Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have previously agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice from your direct health care provider, a representative from Registration or from our web site at the address listed at the end of this Notice.

How we may use and Disclose your Medical Information

The following categories describe the different ways that w use and disclose your medical information. To respect your privacy, we will try to limit the amount of information that we use or disclose to that which is the minimum necessary to accomplish the purpose of the use or disclosure. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information fall within one of these categories.

Treatment. We may use or disclose your medical information with physicians, nurses, technicians, medical and allied health students or other facility personnel in order to provide treatment to 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 so that your nutritional needs can be arranged. Different departments of the facility may also share medical information about you in order to communicate the different services you may need, such a slab work, e-rays and prescriptions. We may also disclose your medical information to those outside the health system who have been involved or may be involved in your medical care, such as other physicians, family members, clergy or others.

Payment. We may use and disclose your medical information to bill and receive payment for the treatment and services you receive.

For example, we may need to give your medical information about a surgery you received at our facility to your health plan so it will pay us or reimburse you for the surgery. We may also tell you health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment. Finally, if applicable, we may share your information with other health care providers and payers for the payment activities.

Health Care Operations. We may use and disclose your medical information in connection with our health care operations. These uses and disclosures are necessary to run our health system and to make sure that all our patients receive quality care.

For example, we may use your medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may disclose information to doctors, nurses, technicians, student and other health care personnel for teaching purposes. We may combine the medical information we have with other health care entities’ information to compare how we are doing and see where we can make improvements in the care and services we offer.

Business Associates. There may be some activities provided for our facility through contracts with outside businesses. Examples include transcription services and collection agencies. Under such contracts, we may disclose your medical information to these businesses to perform the task we have asked them to do. These contracts also require businesses to protect the medical information we disclose to them.

Appointment Reminder. We may use and disclose medical information to contact you as a reminder that you have an appointment or medical care scheduled at our facility.

Treatment Alternatives and Health-Related Benefits & Services. We may use and disclose your medical information to tell you about or recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.

Patient Directory. We may include certain limited information about you in our patient directory while you are at our facility. This information may include your name, location in our facility, general condition (e.g., fair, stable, etc.) and religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest, minister or rabbi, even if they do not ask for you by name. This is so your family, friends and clergy can visit you at our facility and generally know how you are doing. You may request that no information contained in the directory be disclosed.

Persons Involved in your care or Payment for your care. We may share medical information about you to a family member or friend who is involved in your medical care and or helps pay for your care. We may also disclose your information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you are not present or able to object, then we may, using our professional judgment, determine whether the disclosure is in your best interest.

Fundraising Activities. We may use certain information (such as your name, address, telephone number, dates of service) to contact you in the future to seek donations for our community service programs, patient care, and education. We may also share this information with a charitable foundation that will contact you to raise money. If you do not wish us to contact you for fundraising efforts, you must notify us in writing.

As Required by Law. We will disclose your medical information when required to do so by federal, Georgia or local law.

To Prevent a Serious Threat to Health or Safety. We may use and disclose your medical information with others, when necessary, to prevent a serious and imminent threat to your or another person’s health and safety. In such cases, we will only disclose your information with someone able to help prevent this threat.

Special Situations

We may disclose medical information about you when authorized or required to do so by federal, Georgia, or local law or other judicial or administrative proceedings.

Organ and Tissue Donation. If you are an organ donor, we may disclose your medical information 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.

Military and Veterans. If you are a member of the armed forces, we may disclose your medical information as required by military command authorities. We may also disclose medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation. We may disclose your medical information for workers’ compensation or similar programs to the extent necessary to comply with the laws relating to workers’ compensation or other similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose your medical información for public health activities. These activities generally include the following:

§        to prevent or control disease, injury or disability;

§        to report births and deaths;

§        to report child abuse or neglect;

§        to report reactions to medications or problems with products;

§        to notify people of recalls of products they may be using;

§        to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and

§        to 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.

Health Oversight Activities and Registries. We may disclose your medical information to a health oversight agency for activities authorized by law and to patient registries for conditions such as tumor, trauma, and burn. These oversight activities include audits, investigations, inspections and licensure surveys. These activities are necessary for the government to monitor health care systems, government programs, the outbreak of disease, and compliance with civil rights laws and to improve patient outcomes.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your medical information in response to a court or administrative order. We may also disclose your medical information in response to a subpoena, discovery request or other lawful process, but only where a good faith effort has been made by the requesting party to provide you notice of the request and an opportunity to object to the request, or where the requesting party has made a reasonable effort to obtain a court or administrative order protecting the medical information.

Law Enforcement. We may disclose your medical information if asked to do so by a law enforcement official: