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.
I. Who We Are
This Notice describes the privacy practices of Good Samaritan Medical Center (the “Hospital”), including members of its workforce, the physician members of the medical staff, and allied health professionals who practice at the Hospital. The Hospital and the individual health care providers together are sometimes called "us" or "we" in this Notice. While we engage in many joint activities and provide services in a clinically integrated care setting, we each are separate legal entities. This Notice applies to services furnished to you at the main hospital, the Victor Farris Building, the Helen and Harry Gray Cancer Institute, the Good Samaritan North office, and the Good Samaritan West office as a Hospital inpatient or outpatient.
II. Our Privacy Obligations
Each of us is required by law to maintain the privacy of your health information ("Protected Health Information" or "PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
Uses and Disclosures For Treatment, Payment and Health Care Operations. We may use and disclose PHI, but not your “Highly Confidential Information” (defined in Section IV.D below), in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as detailed below:
· Treatment. We use and disclose your PHI to facility personnel and attending physicians for use in connection with the treatment and other services to you--for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment.
· Payment. We may use and disclose your PHI to obtain payment for services that we provide to you from Medicare, the Florida Medicaid program or another governmental program that arranges or pays the cost of some or all of your health care or to verify that such program will pay for health care. We will obtain your authorization to disclose PHI to your private health insurer, HMO or other private payor.
· Health Care Operations. We may use and disclose your PHI for our health care operations, which include risk management, internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses, psychologists, social workers and other health care workers. We may disclose PHI to our Hospital Privacy Office and / or the Patient Liason in order to resolve any complaints you may have and ensure that you have a comfortable visit with us.
We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance. In addition, we may share PHI with our business associates who perform treatment, payment and health care operations services on our behalf.
Use or Disclosure for Directory of Individuals in the Hospital. We may include your name, location in the Hospital, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that your religious affiliation will only be disclosed to members of the clergy.
Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement or instructions to establish a health care surrogate under applicable Florida law; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests in accordance with Federal and Florida law. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location or general condition. Furthermore, if your capacity to make health care decisions for yourself or to provide informed consent is in question, our attending physician shall evaluate your capacity and, if the first physician concludes that you lack capacity, he will enter that evaluation in your medical record. If the attending physician has a question as to whether you lack capacity, another physician shall also evaluate your capacity, and if the second physician agrees that you lack the capacity to make health care decisions or provide informed consent, Hospital shall enter both physicians’ evaluations in your medical record. If you have designated a health care surrogate or have delegated authority to make health care decisions to an attorney-in-fact under a durable power of attorney, we will notify such surrogate or attorney-in-fact in writing that her or his authority under the instrument has commenced, as provided under applicable Florida law.
Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to the Florida Department of Children and Family Services or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect, exploitation or domestic violence, we may disclose your PHI to the Florida Department of Children and Family Services, the Florida Department of Human Services or a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process. Further, unless specifically authorized by a court order, we may not use or disclose PHI identifying you as a recipient of substance abuse program services if the purpose is to initiate or substantiate any criminal charges against you or to conduct any investigation of you. If we do not receive a legal order, we may disclose your PHI in response to a subpoena, discovery request, or other lawful process, that is not accompanied by an order of a court or administrative tribunal, if: (i) we receive satisfactory assurance from the party seeking the PHI that reasonable efforts have been made by such party to ensure that you have been given notice of the request; or (ii) we receive satisfactory assurance from the party seeking the PHI that reasonable efforts have been made by such party to secure a qualified protective order.
Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials including any Florida administrative or regulatory agency, department or other governmental authority with jurisdiction over health care providers or hospital facilities as required or permitted by Federal or Florida law or in compliance with a court order or a grand jury or administrative subpoena.
Decedents. We may disclose your PHI to a coroner or medical examiner as authorized by law.
Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
Research. We may use or disclose your PHI without your consent or authorization as permitted by Florida law if our Institutional Review Board approves a waiver of authorization for disclosure and other requirements of Florida law are satisfied.
Health or Safety. We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety as permitted or required by Florida law.
Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances as permitted or required by law.
Workers’ Compensation. We may disclose your PHI as authorized by and to the extent necessary to comply with Florida law relating to workers' compensation or other similar programs.
As Required by Law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
IV. Uses and Disclosures Requiring Your Written Authorization
Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization on our authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
Payment. We must obtain Your Authorization to disclose PHI to your HMO, health insurer or other private payor to obtain payment for services that we provide to you.
Marketing. We must also obtain Your Authorization prior to using your PHI to send you any marketing materials or utilizing your PHI for solicitation or marketing the sale of goods or services.
Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about genetic testing; (6) is about child abuse and neglect; (7) is about domestic abuse of an adult with a disability; or (8) is about sexual assault. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain Your Authorization.
If we perform a DNA analysis and receive results or findings of DNA analysis, we must provide you with notice that the analysis was performed or that the information was received. The notice must state that, upon your request, the information will be made available to your physician.
V. Your Rights Regarding Your Protected Health Information
For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact the Hospital Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Hospital Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. We will send you a written response.
Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
Right to Revoke Your Authorization. You may revoke Your Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Hospital Privacy Office identified below.
Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you (for example, records relating to termination of pregnancies, contraception and/or family planning services, or the testing of sexually transmitted diseases.) If you desire access to your records, please obtain a record request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. If you request copies, we will charge you $1.00 for each paper page and $2.00 for each nonpaper record page. We will also charge you for our postage costs, if you request that we mail the copies to you.
Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. There may be an additional charge if you request an accounting more than once during a twelve (12) month period.
Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
Effective Date. This Notice is effective on April 14, 2003.
Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around the Hospital and on our Internet site at www.goodsamaritanmc.com. You also may obtain any new notice by contacting the Hospital Privacy Office.
VII. Hospital Privacy Office
You may contact the Hospital Privacy Office at:
Hospital Privacy Office
Good Samaritan Medical Center
1309 N. Flagler Drive
West Palm Beach, FL 33401
Tel Number: (561) 655-5511 E-mail: GSM-privacyofficer@tenethealth.com
Corporate Privacy Office
Tenet HealthSystem
13737 Noel Road, Suite 100
Dallas, Texas 75240
E-mail: PrivacySecurityOffice@tenethealth.com
Ethics Action Line (EAL): 1-800-8-ETHICS |
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