HIPAA
Guidelines
Sierra
Vista Regional Health Center’s notice for use and sharing of protected
health information.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Please review this notice carefully.
You have the right to obtain notice of the uses and disclosures of your protected health information. This notice shall describe your rights pertaining to PHI – Protected Health Information.
Uses
and Disclosures of Your Health Information
- With your consent, we may use your health care information for treatment,
payment, or health care operational purposes. Information that we may use
or disclose includes your health information obtained from this time forward
and all other health information contained in your medical record prior to
date. We may disclose your complete medical record, including portions that
were created by another health care provider, as long as the disclosure is
for the purpose of treatment, payment, or health care operations.
- Your medical information may be used to treat your medical condition or to consider treatment for your medical condition. Your medical record information may also be sent to a specialist physician as a part of a referral.
- Your medical information may also be used to send billing information to a health insurance plan or to obtain payment from other insurers, including, but not limited to, AHCCCS, Medicare, or other third party insurers. If your health information is used for payment purposes, we will only disclose the minimal amount of information that is necessary for payment purposes.
- Your medical information may also be used to evaluate the quality of care that you receive, and for other quality assurance and quality assessment purposes. For example, your health information may be used to compare patient data to approve treatment methods. If your medical information is used for health care operational purposes, we will only disclose the minimal amount of information that is necessary for payment purposes.
- We may use
or disclose identifiable health information about you without your authorization
for several other reasons. Subject to certain requirements, we may give out
health information for reasons such as:
o Public health purposes
o Abuse or neglect reporting
o Auditing purposes
o Research studies
o Funeral arrangements
o Contact for organ donation purposes
o Workers’ Compensation purposes
o Emergencies
o Information when otherwise required by law, such as for law enforcement
in specific circumstances
- We may also contact you about appointment reminders, treatment alternatives, or other health related benefits and services that may be of interest to you.
- If the use or disclosure of your medical information is prohibited or limited by any other applicable law, disclosure of your medical information will comply with the more stringent law.
- Other uses and disclosures of your medical information will be made only with your written authorization.
- If you sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures. In the event that you decide that you do not want your medical information disclosed or used as described above, please notify us in writing immediately.
Your Rights
- You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to such restrictions. If you would like to restrict the use and disclosure of your information, please provide notice to us in writing. You should address your written notification to the Privacy Officer listed at the end of this notice.
- You have the right to request that your health information be communicated to you in a confidential manner. For example, you may request that we send mail to an address other than your home.
- In most cases, you have the right to look at or get a copy of health information about you that we use to make decisions about you. If you request copies, the first five pages are free. For each additional page, we will charge you $.35 (thirty-five cents) for each page. You should note that the fees that we charge for copying your records would not include costs associated with searching for and retrieving the requested information.
- You have the right to request to amend protected health information. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. If we receive and accept your request to amend any health information from you, we may be required to release any such changes to persons who may have relied or could have foreseeably relied upon such information to the detriment of the individual. By requesting an amendment to your protected health information, you consent to the release of the changes.
- You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or related administrative purposes. This right will enable you to receive information regarding who has received your medical information.
- Upon your request, you have the right to obtain a paper copy of this Notice.
- You may request in writing that we not use or disclose your information for treatment, payment, or administrative purposes or to persons involved in your care, except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it.
Duties of Sierra Vista Regional Health Center
Sierra Vista
Regional Health Center:
- Is required by law to protect the privacy of your health information and
to provide you with notice of our legal duties and privacy practices described
in this Notice.
- Is required to abide by the terms of the Notice currently in effect.
- Reserves the right to change our policies at any time and to make the New Notice Provision effective for all protected health information that it maintains. Before we make a significant change in our policies, we will change our Notice and post the new Notice in the waiting areas and each examination room. You can also request a copy of the new Notice at any time. For more information about our privacy practices, contact the Privacy Officer listed below. You may receive a copy of the changed Notice of Privacy practices by requesting a copy from the receptionist or the Privacy Officer, listed below.
Complaints
- If you are concerned that we have violated your privacy rights or you disagree with a decision we made about access to your records, you may contact the Privacy Officer, listed below. You may complain to Cheryl Murphy, HIPAA Privacy Officer. Your complaint to the HIPAA Privacy Officer must be submitted either on paper or electronically. Your complaint must be filed within 180 (one hundred eighty) days from the date that you either knew or should have known that your privacy was violated. The HIPAA Privacy Officer may waive this 180-day time limit if good cause is shown.
- To submit a complaint to the Sierra Vista Regional Health Center, you may file your complaint, specifying the specific reason why you believe your privacy rights have been violated. If possible, please include the name of the Sierra Vista Regional Health Center employee whom you believe to be responsible for violating your privacy rights and the date and time of such violations. You may give your complaints to the receptionist or you may mail your complaint to the Privacy Officer at:
Sierra
Vista Regional Health Center
ATTN: Privacy Officer
300 El Camino Real
Sierra Vista, AZ 85635
- You may e-mail a complaint to: HIPAA@svrhc.org
- You may also file a complaint verbally by telephoning the Privacy Officer
at (520) 417-4994 or by leaving a message with our confidential Compliance
Hotline number at (520) 417-3138.
- Please be assured that in the event that you file a complaint, you will
not be retaliated against for filing such a complaint.
For Further Information
For further information regarding this Notice of Privacy Practices, please contact the Privacy Officer at (520) 417-4994 or e-mail: HIPAA@svrhc.org.
The effective date of this notice is April 1, 2003.
Corporate
Compliance
Cheryl Murphy, Compliance Coordinator
(520) 417-4994
Ensuring a comprehensive strategy of adherence to all applicable laws and regulations is the mission of Sierra Vista Regional Health Center’s Corporate Compliance program. Our program is consistent with the standards set forth in the Federal Sentencing Guidelines for Organizations and the draft OIG Model Compliance Plan for Hospitals. The Compliance Program is intended to prevent, detect, and report violations of federal, state, and local laws and to create an environment in which employees and physicians with SVRHC conduct their daily activities in compliance with these laws.
Any information you think should be forwarded can be reported with complete confidentiality by calling the hospital’s Compliance HOTLINE at (520) 417-3138.
We respect your privacy interests and so operate this site by these principles:
• You may use Sierra Vista Regional Health Center’s web site without disclosing personally identifiable information. We want to be clear that we will not obtain such information about you unless you choose to submit to us. For example, by e-mailing us your comments or suggestions, that identifies your e-mail address.
• We have taken reasonable steps to ensure the integrity and confidentiality of personally identifiable information that you may provide. You should understand, however, that electronic transmissions via the Internet are not necessarily secure from interception and so we cannot guarantee the security or confidentiality of such transmissions.
• Please note that we do not use “cookies” which are small files stored on your computer’s hard drive that are used to track personal information.
• Except for authorized law enforcement investigations or other valid legal processes, we will not share any information we receive with any outside parties.
• HIPAA Compliance Security Officer, Jorge Moreno (520) 417-3304.
Everyone
has a role in making health care safe - physicians, health care executives,
nurses, and technicians. Health care organizations across the country are
working to make health care safety a priority. You, as our patient, can also
play a vital role in making your care safe by becoming an active, involved,
and informed member of your health care team.
Speak up if you have questions or concerns, and if you don’t understand, ask again. It’s your body and you have a right to know.
• Your
health is too important to worry about being embarrassed if you don’t
understand something that your doctor, nurse, or other healthcare professional
tells you.
•
Don’t be afraid to ask about safety. If you’re having surgery,
for example, ask the doctor to mark the area that is to be operated on, so
that there’s no confusion in the operating room.
•
Don’t be afraid to tell the nurse or doctor if you think you are about
to receive the wrong medication.
•
Don’t hesitate to tell the healthcare professional if you think he or
she has confused you with another person.
Pay attention to the care you are receiving. Make sure you’re getting the right treatments and medication by the right healthcare professionals. Don’t assume anything.
•
Tell your nurse or doctor if something doesn’t seem quite right.
• Expect health care workers to introduce themselves when they enter
your room and look for their identification badges. A new mother, for example,
should know the person to whom she is handing her baby. If you are unsure,
ask.
•
Notice whether your caregivers have washed their hands. Hand washing is the
most important way to prevent the spread of infections. Don’t be afraid
gently remind a doctor or nurse to do this.
•
Know what time of day you normally receive a medication. If this does not
happen, bring this to the attention of your doctor or nurse.
•
Make sure your nurse or doctor confirms your identity, that is, checks your
wristband or asks your name, before he or she administers any medication or
treatment.
Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan.
•
Ask your doctor about the specialized training and experience that qualifies
him or her to treat your illness (and be sure to ask the same questions of
those physicians to whom he or she refers you).
•
Gather information about your condition. Good sources include your doctor,
your library, respected websites, and support groups.
•
Write down important facts your doctor tells you, so that you can look for
additional information later. And ask your doctor if he or she has any written
information you can keep.
•
Thoroughly read all medical forms and make sure you understand them before
you sign anything. If you don’t understand, ask your doctor or nurse
to explain.
•
Make sure you are familiar with the operation of any equipment that is being
used in your care. If you will be using oxygen at home, do not smoke or allow
anyone to smoke near you while oxygen is in use.
Ask a trusted family member or friend to be your advocate.
•
Your advocate can ask questions that you may not think of while you are under
stress.
•
Your advocate can also help remember answers to questions you have asked,
and speak up for you if you cannot.
•
Make sure this person understands your preferences for care and your wishes
concerning resuscitation and life support.
•
Review consents for treatment with your advocate before you sign them and
make sure you both understand exactly what you are agreeing to.
•
Make sure your advocate understands the type of care you will need when you
get home. Your advocate should know what to look for if your condition is
getting worse and whom to call for help.
Know what medications you take and why you take them. Medication errors are the most common health care mistakes.
•
Ask about the purpose of the medication and ask for written information about
it, including its brand and generic names. Also inquire about the side effects
of the medication.
•
If you do not recognize a medication, verify that it is for you. Ask about
oral medications before swallowing, and read the contents of bags of intravenous
(IV) fluids. If you’re not well enough to do this, ask your advocate
to do this.
•
If you are given an IV, ask the nurse how long it should take for the liquid
to “run out.” Tell the nurse if it doesn’t seem to be dripping
properly (that it is too fast or too slow).
•
Whenever you are going to receive new medication, tell your doctors and nurses
about allergies you may have, or negative reactions you have had to medications
in the past.
•
If you are taking multiple medications, ask your doctor or pharmacist if it
is safe to take those medications together. This holds true for vitamins,
herbal supplements and over-the-counter drugs, too.
•
Make sure you can read the handwriting on any prescriptions written by your
doctor. If you can’t read it, the pharmacist may not be able to either.
Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous on-site evaluation against established, state-of-the-art quality and safety standards, such as that provided by Joint Commission.
•
Ask about the health care organization’s experience in treating your
type of illness. How frequently do they perform the procedure you need and
what specialized care do they provide in helping patients get well?
• If you have more than one hospital or other facility to choose from,
ask your doctor which one offers the best care for your condition.
• Before you leave the hospital or other facility, ask about follow-up
care and make sure you understand all of the instructions.
• Go to Quality Check at www.jointcommission.org
to find out whether your hospital or other health care organization is accredited.
Participate in all decisions about your treatment. You are the center of the health care team.
•
You and your doctor should agree on exactly what will be done during each
step of your care.
•
Know who will be taking care of you, how long the treatment will last, and
how you should feel.
•
Understand that more tests or medications may not always be better. Ask your
doctor what a new test or medication is likely to achieve.
•
Keep copies of your medical records from previous hospitalizations and share
them with your health care team. This will give them a more complete picture
of your health history.
•
Don’t be afraid to seek a second opinion. If you are unsure about the
nature of your illness and the best treatment, consult with one or two additional
specialists. The more information you have about the options available to
you, the more confidant you will be in the decisions made.
•
Ask to speak with others who have undergone the procedure you are considering.
These individuals can help you prepare for the days and weeks ahead. They
also can tell you what to expect and what worked best for them as they recovered.
The “Speak Up” program, sponsored by the Joint Commission on Accreditation of Healthcare Organizations, urges patients to get involved in their care. Such efforts to increase consumer awareness and involvement are supported by the Centers for Medicare Services. This initiative provides simple advice on how you, as the patient, can make your care a positive experience. After all, research shows that patients who take part in decisions about their health care are more likely to have better outcomes.
If you have questions about the speak up program at Sierra Vista Regional Health Center, please contact Mandy Budny, BSN, Quality Manager at (520) 417-4542 or by e-mail at mandy.budny@svrhc.org.