|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.|
Patient Health Information
Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing and insurance information.
How We Use Your Patient Health Information
We use health information about you for treatment, to obtain payment, and for health care operations, including administrative purposes and evaluation of the quality of care you receive. Under some circumstances, we may be required to use or disclose the information even without your consent.
Who Will Follow this Notice
This notice describes the practices of the following entities which are a part of Gonzales Healthcare Systems: Memorial Hospital, Memorial Hospital Home Health Agency, Sievers Medical Clinic, Waelder Medical Clinic, Health Solutions Store, and Heritage Program for Senior Adults. This notice also serves as notice of the privacy practices of members of the Hospital Medical Staff and any other health care professionals who may provide medical care and treatment at the Hospital.
Examples of Treatment, Payment and Health Care Operations
Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care.
Payment: We will use and disclose your health information so that the treatment and services you receive at the Hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will also submit bills and maintain records of payments from you, your health plan or a third party.
Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, and to assess the care and outcomes of your case and others like it.
Other Uses and Disclosures
We may use or disclose identifiable health information about you for other reasons without your permission. Subject to certain requirements, we are permitted to give out health information without your permission for the following purposes:
Required by Law: We may be required by law to report gunshot wounds, suspected abuse or neglect or similar injuries and events.
Public Health Activities: As required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.
Health Oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.
Judicial and Administrative Proceedings: We may disclose information in response to an appropriate subpoena or court order.
Law Enforcement Purposes: Subject to certain restrictions, we may disclose information required by law enforcement officials.
Deaths: We may report information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.
Serious Threat to Health or Safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and Special Government Functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes.
Research: We may use or disclose information for approved medical research.
Workers Compensation: We may release information about you for workers compensation or similar programs providing benefits for work-related injuries or illnesses.
Appointment Reminders: We may contact you to provide a reminder that you have an appointment for treatment or medical care at the hospital.
Treatment Alternatives: We may contact you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Fundraising: We (or a foundation related to the hospital) may contact you to raise funds for the hospital and its operations. You may opt out of receiving fundraising communications by submitting a written request to the Privacy Officer at the address listed below.
Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition and religious affiliation in our patient directory. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name unless you object.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care.
Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Auxiliary: If you wish to receive certain services provided by the hospital auxiliary, we may have to share some health information about you with the auxiliary.
Business Associates: There are some services our organization provides through contracts with business associates. When such services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third party payor for services rendered. However, we do require the business associate to appropriately safeguard your information and your rights described below apply to health information maintained by the business associate.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you sign an authorization to use or disclose your health information, you may revoke that permission, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your authorization. We are unable to take back any disclosures we have already made with your authorization.
You have the following rights with regard to your health information maintained by us. To exercise any of these rights, you must submit a written request to the Privacy Officer at the address listed below.
Right to Inspect and Copy: You have the right to look at and copy your health information maintained by us, except for psychotherapy notes. If you request a copy of the information, we may charge a reasonable fee for the costs of copying and mailing or other costs associated with your request. We may deny your request to inspect and copy your health information in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. A licensed health care professional (other than the person who denied your request) chosen by us will review your request and the denial. We will comply with the reviewer’s decision.
Right to Amend: If you feel that your health information maintained by us is incorrect or incomplete, you have the right to ask us to amend the information. Your request to amend must include a reason for amendment that supports your request. We may deny your request for an amendment if you ask us to amend information that:
Was not created by us, unless the person/entity that created the information is no longer available to make the amendment;
Is not part of the health information kept by or for us;
Is not part of the information you would be permitted to inspect and copy; or
Is accurate and complete.
Right to Accounting of Disclosures: You have the right to request an “accounting of disclosures” of health information made by us in the six years prior to the date on which the request is made. We are not required to provide you with an accounting of certain types of disclosures, including but not limited to disclosures for treatment, payment or health care operations, or disclosures otherwise permitted or required by law. Your request for an accounting must state a time period not longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free; we may charge you for additional lists requested within a 12-month period.
Right to Request Restrictions: You have the right to ask us to restrict our uses and disclosures of your health information for treatment, payment or health care operations. We are not required to agree to your request, but if we do, we will honor the request.
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide this Notice about your legal duties and privacy practices regarding protected health information, and to abide by the terms of the Notice currently in effect.
Changes in Privacy Practices
We may change our policies at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice in admissions areas. You can also request a copy of our Notice at any time. For more information about our privacy practices, contact the person listed below.
If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below will provide you with the appropriate address upon request. You will not be penalized in any way for filing a complaint.
If you have any questions, requests, or complaints, please contact:
Gonzales Healthcare Systems
PO Box 587
Gonzales, Texas 78629
Gonzales Healthcare Systems and the physicians who practice in its facilities are independent contractors and do not hereby assume any liability for the services or conduct of each other.
The effective date of this Notice is April 14, 2003.