AVERA QUEEN OF PEACE HEALTH SERVICES
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE - APRIL 14, 2003
PLEASE REVIEW THIS NOTICE CAREFULLY
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
If you have any questions about any information contained in this Notice, please contact the Avera Queen of Peace Privacy Office at the address or phone number at the end of the Notice.
Who will follow the directives outlined in this notice?
Avera Queen of Peace Health Services provides health care to our patients, residents, and clients in partnership with physicians and other professionals and organizations. Information privacy practices in this Notice will be followed by:
- All departments and units of our organization, including Avera Brady Health and Rehab, Avera Brady Assisted Living, Avera Corsica Medical Clinic, Avera Salem Family Medical Clinic and Avera St. Joseph Clinic.
- Any credentialed medical staff or health care professional who treats you at any of our locations as listed above.
- All employed associates, staff or volunteers of our organization with whom we may share information, including staff at Avera Queen of Peace.
- Any business associate or partner of Avera Queen of Peace with whom we share health information.
Our pledge to you.
We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This Notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office. We are required by law to:
- Keep private any medical information about you.
- Give you this Notice of our legal duties and privacy practices with respect to medical information about you.
- Follow the terms of the Notice that is currently in effect.
Changes to this Notice.
Polices may be changed at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will revise our Notice and post the new Notice in waiting areas, exam rooms, and on our Web site at www.averaqueenofpeace.org. You can receive a copy of the current Notice at any time. The effective date is listed just below the title. You will be offered a copy of the current Notice at your first visit for treatment following the effective date. You will also be asked to acknowledge in writing your receipt of this Notice.
How we may use and disclose medical information about you.
- We may use and disclose medical information about you for treatment (such as sending medical information about you to a specialist as part of a referral); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support our health care operations (such as comparing patient data to improve treatment methods.)
- We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, research studies, funeral arrangements and organ donation, workers’ compensation purposes, and emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders.
- We also may contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you, or to support fundraising efforts.
- If admitted as a patient, unless you tell us otherwise, we will list in the patient directory your name, location in the hospital, and your religious affiliation and will release all but your religious affiliation to anyone who asks about you by name. Your religious affiliation may be disclosed only to a clergy member, even if they do not ask for you by name.
- We may disclose medical information about you to a friend or family member who is involved in your medical care, or to disaster relief authorities so that your family can be notified of your location and condition.
Other uses of medical information.
- In any other situation not covered by this Notice, we will ask for your written authorization before using or disclosing medical information about you. If you chose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.
Your rights regarding medical information about you.
- In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
- If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we amend the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that record is accurate. You may appeal, in writing, a decision by us not to amend a record.
You have the right to a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003 . The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.
You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you.
You may request in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request, but we are not legally required to accept it. We will inform you of our decision on your request.
All written requests or appeals should be submitted to our Privacy Officer listed at the bottom of this Notice.
- If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer (listed below). You may also contact our Corporate Compliance Officer at 605-995-2000 or the Avera Health Help Line at 1-888-881-8395.
- Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Officer can provide you the address.
- Under no circumstance will you be penalized or retaliated against for filing a complaint.
Privacy Officer at Avera Queen of Peace Health Services
525 North Foster, Mitchell, SD 57301-2999
Phone: 605-995-2000 FAX: 605-995-2287