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HIPAA Notice of Privacy Practices
Effective Date of this Notice: June 1, 2010
VINCENTIAN COLLABORATIVE SYSTEM
NOTICE OF PRIVACY PRACTICES
THIS NOTICE APPLIES TO MARIAN MANOR, VINCENTIAN de MARILLAC, VINCENTIAN HOME, AND VINCENTIAN PERSONAL CARE
THIS NOTICE DESCRIBES HOW HEALTH 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 Social Services.
Violations of this Notice should be reported to Social Services or to Donna Schaub, Corporate Compliance Officer, Vincentian Collaborative System (412) 630-9980. Violations may also be reported anonymously to the Compliance Hotline at 1-866-435-2201. The Compliance Hotline is answered 24 hours a day/7 days a week.
Who Follows this Notice of Privacy Practices
Vincentian Collaborative System (VCS) is made up of many people, nurses, dieticians, rehabilitation services and other related health care providers. This also includes our Medical Directors, students, trainees, volunteers and others involved in providing your care. These people may share your health information with each other for the treatment, payment, or health care operations that this Notice describes. This Notice does not apply to Vincentian Collaborative System or its nursing homes as an employer. Also, your doctor will have his or her own Notice of Privacy Practices and may have different rules about how he or she handles your health information.
This is not meant to be a complete listing of all the Vincentian Collaborative System (VCS) places and people who may provide you with care. If you have any questions as to whether the care you receive is covered under this Notice, please contact Social Services or the VCS Corporate Compliance Officer at 412-630-9980.
A. OUR COMMITMENT TO YOUR PRIVACY
Vincentian Collaborative System is dedicated to maintaining the privacy of your health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you.
These records are our property. However, we are required by law:
• To maintain the confidentiality of your health information;
• To provide you with this notice of our legal duties and privacy practices concerning your health information;
• To abide by the terms of our Notice of Privacy Practices;
• To obtain your written authorization to use or disclose your health information for reasons other than those listed herein and permitted under law;
• To accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and
• To notify you if we are unable to agree to a requested restriction on how your health information is disclosed.
To summarize, this notice provides you with the following important information:
• How we may use and disclose your health information.
• Your privacy rights in your health information.
• Our obligations concerning the use and disclosure of your health information.
CHANGES TO THIS NOTICE
The terms of this notice apply to all records containing your health information that are created or retained by us. We reserve the right to revise, change, or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your information that we already have about you, as well as any of your health information that we may receive, create, or maintain in the future. Our organization has posted a copy of our current notice in the lobby and on our website at www.vcs.org. You may request a copy of our most current notice during any visit to our organization by contacting Social Services.
B. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe the different ways in which we may use and disclose your health information. Please note that each particular use or disclosure is not listed below. However, the different ways we are permitted to use and disclose your health information do fall within one of the following categories.
We may use and disclose your health information to treat you. For example, you may have to undergo laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. Individuals who are employed at our facility may use or disclose your health information in order to treat you. Additionally, we may disclose your health information to others that may assist in your care, such as your physician, therapists, spouse, and/or other family member. However, should you not wish to share this information with a family member or members, please contact Social Services. All such requests must be made in writing.
We may use and disclose your health information in order to bill and collect payment for the services and items received. For example, we may contact your health insurer to certify that you are eligible for benefits. We may provide your insurer with details regarding your treatment to determine if your insurer will pay for your treatment. We may use and disclose your health information with third parties that are responsible for payment of such costs. Your health information may be used to bill you directly for services and items.
Health Care Operations
We may use and disclose your health information to conduct health care operations. These uses and disclosures are important to ensure that you receive quality care. For example, we may use your health information to evaluate the quality of care you receive or to conduct cost-management and business planning activities. Further, we may disclose your information to doctors, nurses, and other personnel for their review and learning purposes.
Treatment Alternatives/Health-Related Benefits and Services
We may use and disclose your health information to inform you of treatment alternatives and/or health-related benefits and services that may be of interest to you. For example, you may qualify for hospice care.
We may use or share your health information for marketing purposes, only when we discuss such products or services with you face-to-face or provide you with an inexpensive promotional sample of the product or service. For other types of marking activities, we will obtain your written permission. We will not sell your name to others. If you do not want to receive marketing communications (other than those that are in a newsletter), please contact Social Services at 412-366-5600. All such requests must be made in writing.
In addition, if we ever use or disclose your health information to communicate with you based on your particular health status or condition, we will explain to you why you received the communication, and how the product or service relates to your health.
Sharing General Information with Family/Friends and the Privacy Code
Should people call about you and ask for you by name while you are a resident in our facility, we will share limited information about you. This information may include your name, location, and your general condition. We will place your name on the door to your room.
For family and friends with whom you would like us to share your health information, you may share with them your Privacy Code. The Privacy Code is your authorization for us to share more information about you, such as your diagnosis, test results, and any treatment regime that you may undergo. Anyone contacting us without the Privacy Code will only receive the limited information identified in the above paragraph. If you wish to change your Privacy Code, please contact Social Services.
Your religious affiliation will be given to our Pastoral Care Department and appropriate staff. We may share information about you with your pastor, minister or church representative. This information may include your name, location, and your general condition. If you do not want this information shared with your pastor, minister or church representative, you should inform Social Services. All such requests must be made in writing.
We will maintain a facility directory which contains your name and your room number. The information contained in the directory may be released to people who ask for you by name. This helps your family, friends and clergy to visit you or contact you. You have the right to ask that all or part of your information not be given out. If you do so, we will not be able to tell your family or friends your room number or that you are in our facility.
We may also list your name on a bulletin board as part of an activity such as our Birthday Club or to welcome you to our facility. We may also publicize your name in our newsletter for residents and their families.
If you do not want your information in our facility directory, you should inform Social Services. All such requests must be made in writing.
The following categories describe additional conditions in which we may use or disclose your health information:
Required by Law. We will use or disclose health information about you when required by applicable law.
Public Health Activities
We may disclose your health information for public health activities, including generally:
• to prevent or control disease, injury or disability;
• to maintain vital records, such as births and deaths;
• to report elder abuse or neglect;
• to report injury, elopement or other potential harm to a resident as required by the PA Department of Health;
• to notify a person regarding potential exposure to communicable disease;
• to notify a person regarding a potential risk for spreading or contracting a disease or medical condition;
• to report reactions to drugs or problems with medical products or devices;
• to notify individuals if a medical product or device they may be using has been recalled.
Abuse, Neglect and Injury
We may disclose your health information to a government authority if we believe you are a victim of abuse, neglect or domestic violence. If we make such a disclosure, we will inform you or your responsible party of it, unless we think that informing you places you at risk of serious harm or is otherwise not in your best interest.
Health Oversight Activities
We may disclose your health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.
Lawsuits and Similar Proceedings
We may use and disclose your health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
We may release health information if asked to do so by law enforcement officials:
• regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
• concerning a death we believe might have resulted from criminal conduct;
• regarding criminal conduct in or around our nursing home;
• in response to a warrant, summons, court order, subpoena or similar legal process;
• to identify/locate a suspect, material witness, fugitive or missing person; and
• in an emergency, to report a crime including the location or victim(s) of the crime, or the description, identity of the perpetrator.
Coroners, Medical Examiners, and Funeral Directors
We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release health information about residents to funeral directors as necessary to carry out their duties.
Serious Threats to Health or Safety
We may use and disclose your health information, when necessary, to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Specialized Government Functions
We may disclose your health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, we may disclose your health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
We may release your health information for workers’ compensation and similar programs if you have made a claim for benefits.
C. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding the health information that we maintain about you:
You have the right to request a restriction in our use or disclosure of your health information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your health information to individuals involved in your care or the payment for your care, such as family members and friends. Please see how our Privacy Code Program can assist you on the bottom of Page 4.
We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
In order to request a restriction in our use or disclosure of your health information, you must make your request in writing to Social Services. Your request must describe in a clear and concise fashion: (1) the information you wish restricted; (2) whether you are requesting to limit our facility’s use, disclosure or both; and (3) to whom you want the limits to apply.
You have the right to request that we communicate with you about your health and related issues in a particular manner, or at a certain location. For instance, you may ask that we discuss your health with you in a private place or with the door closed. Your Power of Attorney (POA) may request contact by telephone, or at home, rather than work.
In order to request a type of confidential communication, you must make a written request to Social Services, specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request.
Inspection and Copies
You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including your medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Director of Nursing in order to inspect and/or obtain a copy of your medical information. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted not by the person that denied your request, but by another licensed health care professional chosen by us.
You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or used by us. To request an amendment, your request must be made in writing and submitted to the Director of Nursing. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is:
• accurate and complete;
• not part of the health information kept by us;
• not part of the health information which you would be permitted to inspect and copy; or
• not created by us, unless the individual or entity that created the information is not available to amend the information.
Accounting of Disclosures
You have the right to request an accounting of disclosures. An accounting of disclosures is a list of disclosures of your health information made without your authorization or outside of treatment, payment and healthcare operations. In order to obtain an accounting of disclosures, you must submit your request in writing to Social Services. All requests for an accounting of disclosures must state a time period that may not be longer than six years. The first list you request within a 12-month period is free of charge, but we may charge you for additional requests within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice
You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Social Services.
Right to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint by contacting Social Services or Donna Schaub, Corporate Compliance Officer.
You will not be penalized for filing a complaint.
Right to Provide an Authorization for Other Uses and Disclosures
We will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your permission. Please note that we are required to retain records of your care.