NOTICE OF PRIVACY PRACTICES
Effective:
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.
This notice will tell you how we may use and disclose (give to others) health information about you. We use and disclose medical information about you for a number of different purposes as described in the following:
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We may use medical information about you to
provide treatment, coordinate or manage your health care and related
services. We may disclose medical
information about you to other health care providers who become involved in
your care. We may consult with other
health care providers concerning you and as part of the consultation share your
medical information with them. For example, if you need to receive services from a physician with a particular
specialty, we will disclose medical information to them or their office so they
have the information they need to provide services for you.
§
We may use and disclose medical information
about you so we can be paid for the services we provide to you. We do this to bill you, your insurance
company, Medicare, Medicaid or a third party payor. For example, we may need to give your insurance company information about the health
care services we provide to you so your insurance company can determine
eligibility for payment and will pay us for those services or reimburse you for
amounts you have paid. If a grant
funding source is paying for the services you receive, we may be required to
give them information about you and your treatment.
§
We may use and disclose medical information
about you for our own health care operations.
These are necessary for us to operate MCHD and to maintain quality
health care for our patients. For
example, we may use medical information
about you to review the services we provide and the performance of our
employees in caring for you. We may
disclose medical information about you to train our staff and students working
at MCHD. We also may use the information
to study ways to more efficiently manage our organization.
Unless you tell us otherwise in writing, we may contact you by either telephone or by mail at either your home or your workplace. We may leave messages for you on the answering machine or voice mail. We may use and disclose medical information about you to contact you to remind you of an appointment you have with us. We may use and disclose medical information about you to contact you about treatment alternatives or health related benefits or services that may be of interest to you. If you want to request that we communicate to you in a certain way or at a certain location, you have the right to request how we communicate medical information about you to you. For example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the confidential communication.
If you want to request confidential communication, you must do so in writing to the Privacy contact person or the Privacy Officer. Your request must state how or where you can be contacted. We will accommodate reasonable requests. However, we may require information from you concerning how payment will be handled.
We may disclose to a family member, other relative, a close personal friend, or any other person identified by you, medical information about you that is directly relevant to that person’s involvement with your care or payment related to your care. We also may use or disclose medical information about you to notify, or assist in notifying, those persons of your location, general condition, or death. If there is someone, such as a family member, other relative or close personal friend, you do not want us to disclose medical information about you, please notify the Privacy Contact person or the Privacy Officer.
Subject to certain requirements, we may give out health information without your authorization for –
o As required by law.
o To identify or locate a suspect, fugitive, material witness or missing person.
o About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed.
o To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct
o About crimes that occur at our facility.
o To report a crime in emergency circumstances.
Other Uses and Disclosures.
Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying the Privacy Officer in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance of it.
Your Rights With
Respect to Medical Information About You.
You have the following rights with respect to medical information that we maintain about you.
You have the right to request that we restrict the uses or disclosures of medical information about you to carry out treatment, payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to any other person identified by you.
For example, you could ask that we not disclose medical information about you to a family member.
To request a restriction, you may do so at this time or at any other later time. If you request a restriction, you should do so to the Privacy Officer or the Privacy Contact person. And tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and, (c) to whom you want the limits to apply (for example, disclosures to you spouse).
We are not required to agree to any requested restriction. If we do agree to the restriction, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction.
With a few very limited exceptions you have the right to inspect and obtain a copy of medical information about you.
You must submit your request in writing to the Privacy Officer. Your request should state specifically what medical information you want to inspect or copy. If you request a copy of the information, we may charge a fee for the costs of copying, and if you ask that it be mailed to you, the cost of mailing.
We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.
We may deny your request to inspect and copy medical information if the medical information involved is:
If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designated by us who was not directly involved in the denial. We will comply with the outcome of that review.
You have the right to ask us to amend medical information about you. You have this right for as long as the medical information is maintained by us.
To request an amendment, you must submit your request in writing to the Privacy Officer. Your request must state the amendment desired and provide a reason in support of that amendment.
We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying. If we grant the request, in whole or in part, we will seek your identification of and agreement to share the amendment with relevant other persons. We also will make the appropriate amendment to the medical information by appending or otherwise providing a link to the amendment.
We may deny your request to amend medical information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. In addition, we may deny your request to amend medical information of we determine that the information:
If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of disagreeing with our denial. Your statement may not exceed 4 pages. We may prepare a rebuttal to that statement. Your request for amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any, will then be appended to the medical information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the medical information involved.
You also have the right to complain about our denial of your request.
You have the right to receive an accounting of disclosures of medical information about you.
The accounting may be for up to
six (6) years prior to the date on which you request the accounting but not
before
Certain types of disclosures are not included in such an accounting:.
Under certain circumstances your right to an accounting of disclosures may be suspended for disclosures to a health oversight agency or law enforcement official. Should you request an accounting during a period of time your right is suspended, the accounting would not include the disclosure or disclosures to a law enforcement official or to a health oversight committee.
To request an accounting of disclosures, you must submit
your request in writing to the Privacy Officer.
Your request must state a time period for the disclosures. It may not be longer than six (6) years from
the date we received your request and may not include dates before
The current Notice of Privacy Practices will be posted in the waiting areas of the MCHD premises. You have the right to obtain a paper copy or an e-mail copy of our Notice of Privacy Practices. You may request a copy of our Notice of Privacy Practices at any time. To obtain a paper copy of this notice, contact the Privacy Officer or Privacy contact person at MCHD (217) 532-2001. You may obtain a copy of the current Notice of Privacy Practices over the Internet at our Website, www.montgomeryco.com/health.
Our Duties
We are required by law to maintain the privacy of medical information about you and to provide individuals with notice of our legal duties and privacy practices with respect to medical information. We are required to abide by the terms of our Notice of Privacy Practices in effect at the time. We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all medical information that we maintain, including that created or received by us prior to the effective date of the new notice.
The effective date of the notice will be stated on the first page of the notice.
You may complain to us and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.
To file a complaint with us, contact the Privacy Officer at
11191 IL. Rt. 185,
To file a complaint with the United States Secretary of
Health and Human Services, send your complaint to him or her in care of: Office of Civil Rights, U.S. Department of
Health and Human Services,
You will not be retaliated against for filing a complaint.
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact the Privacy Officer at the Montgomery County Health Department at 532-2001.
Acknowledgement of Receipt of NOPP
I have received a copy of Montgomery County Health Departments Notice of Privacy Practices effective ____________________________ on the date stated below.
_______________________________ ____________________ ________________________
Client signature Date Identification number
_______________________________ _____________________
Signature of Personal Representative Date
_______________________________________________________
Description of Representative’s authority to act for the client
_______________________________ ______________________
MCHD staff signature Date
Describe efforts to obtain a
written acknowledgement and why one was not obtained (if applicable)-
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________ _______________________
MCHD staff signature Date
This page must be completed and filed in
the client’s chart.