JOINT NOTICE OF PRIVACY PRACTICES
This Notice describes how information about you may be used and disclosed by Sheridan Community Hospital and how you can get access to this information. Please review this Notice carefully.
THIS NOTICE APPLIES TO THE PRIVACY PRACTICES OF:
USING AND DISCLOSING YOUR HEALTH INFORMATION
Each time you visit a hospital, physician, or other health care provider, a record of your visit and the care provided to you during that visit is made. Typically, this record contains information regarding your health history, symptoms, examinations, and tests performed including the results of those tests, any diagnoses or treatment, and any plan for future care or follow-up with respect to your condition or treatment. Some of this information may be collected from other health care providers. This information is often referred to as your medical record. When we create a record or collect this type of health information about you, we use it for current and future treatment purposes, to obtain payment for treatment provided to you, for administrative and operational purposes, and to evaluate the quality of the care provided to you. By way of example, we may use or disclose certain identifiable health information about you, without your authorization for other reasons such as:
We routinely provide patient health information when otherwise required by law, such as when law enforcement officials are entitled to such information in specific circumstances. In many other instances, we will ask for written authorization before using or disclosing any identifiable health information about you. If we request one and you choose to sign an authorization to disclose your protected health information, you can later revoke that authorization to stop future uses and disclosure of that information without your consent.
We may change our policies or practices regarding the use of your health information from time to time. Before we make a significant change in our policies or practices, we will change our Notice and post the new Notice throughout the facility and on our web site at www.sheridanhospital.com. You have a right to a written copy of and can always request a copy of our current Notice, at any time. For more information about our privacy practices and policies, please contact the individual and office listed below.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of Sheridan Community Hospital the information contained within your health record belongs to you. You have a right to request the restriction of certain uses and disclosures of your information. You also have the right to amend and request changes in the information contained within your health record and to obtain an accounting of disclosures of your health information when such disclosures are made for other than treatment, payment, related administrative, or operating purposes as described above. Any request to amend your record must be made in writing and we may deny your request if it:
Any request for an accounting of disclosures of your information must be in writing, can be for a time period no longer than six years, and may not include a period of time prior to April 14, 2003. The first disclosure list you request within a 12 month period is free. For any additional request, we may charge you for the cost of providing the list.
You may request, in writing, that we not use or disclose your information for treatment, payment, or administrative purposes except when specifically authorized by you, when required by law, or emergency circumstances. We will consider your request, but you should be aware that we are not legally required to accept it and may, if we deem your request too restrictive, elect not to treat you or to disregard it in an emergency situation. You have the right to restrict or prohibit some or all of the uses or disclosures of your information from the facility's directory, including your name, location in the facility, general conditions, and religious affiliation.
You have the right, with limited exceptions, to inspect and obtain a copy of your health record. Usually this includes medical and billing records, but may not include records such as psychotherapy notes. If you request copies of your health records, the request must be in writing and we will charge you an initial $5.00 retrieval fee and $.25 per page for such copies. This charge is directly attributable to the administrative and copying costs associated with meeting your request. If your request for copies of your health record is, in your opinion, an emergency, please let us know as we do not intend to deny you access to your health records or information in an emergency circumstance and will work with you to meet these emergency needs.
You also have the right to request that we communicate with you about medical matters in certain ways or at certain locations. Again, this request should be in writing and should be specific as to how and where you wish to be contacted. We do not need to know the reasons for your request.
We are required by law to maintain the privacy of your health information, provide you with this Notice of our legal duties and privacy practices, and to abide by the terms of this Notice.
If you are concerned that we have violated your privacy rights, our own policies as summarized in this Notice, or if you disagree with a decision we made about access to your records, you may contact the person listed below. You may also send a written complaint to the United States Department of Health & Human Services. The person and office listed below can provide you with the appropriate address upon request. You will not suffer any retaliation for filing a complaint.
We are required by law to protect the privacy of your information and to provide you with this Notice about our information practices. We are also required to abide by the terms of this Notice and to notify you if we are unable to agree to a requested restriction you have made relative to the use or disclosure of your information. In addition, we are required to accommodate reasonable requests you make regarding the communication of your health information by alternate means or at alternative locations.
If you have any questions regarding this Notice, our use or disclosure of your health information, or if you wish to file a complaint regarding our use or disclosure of your health information, please contact:
HIPAA Compliance Officer
Sheridan Community Hospital
301 N. Main Street, P.O. Box 279
Sheridan, Michigan 48884
Phone: (989) 291-3261
Hotline: (866) 493-4181
Effective Date of this Notice: April 14, 2003