Red
Cliff Community Health Center
88455
Pike Road
P.O.
Box 529
Bayfield,
WI 54814
(715)
779-3707
Notice
of Privacy Practices
“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.”
April 2003
I. Understanding Your Health Record/Information
Each time you visit the Red Cliff Community Health Center,
Ambulance service, AODA service, and Pharmacy services, a record of your visit
is made. Typically, this record contains your symptoms, examination, test
results, diagnoses, treatment, and a plan for future care. This information,
often referred to as your health record, serves as a:
· Plan for your care
and treatment
· Communication source
between the health care professionals
· Tools with which we
can check result and continually work to improve the care we provide
· Means by which
Medicare, Medicaid or private insurance payers can verify the services billed.
· Tool for education of
health care professionals
· Source of information
for public health authorities charged with improving the health of the people
· Source of data for
medical research, facility planning and marketing
· Legal document that
describes the care you receive
Understanding what is in your health record and how the
information is used helps you to:
· Ensure
its accuracy
· Better understand why
others may review your health information
· Make an informed
decision when authorizing disclosures
II. Red Cliff Community Health Center, Ambulance,
AODA, and Pharmacy Responsibilities
The Red Cliff Community Health Center, Ambulance, AODA, and
Pharmacy is required by law to:
· Maintain the privacy
of your health information
· Inform you about our
privacy practices regarding health information we collect and maintain about
you
· Honor terms of this
notice
Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy reserves the right to change its privacy
practices and to make the new provisions effective for all protected health
information it maintains.
Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy will post any revised Notice of Privacy Practices
at public places in each physical facility on or after the effective date of
the revision and you may request a copy of the notice.
Red Cliff Community Health Center, Ambulance, AODA, and Pharmacy
understands that health information about you is personal and is committed to
protecting your health information.
Red Cliff Community
Health Center, Ambulance, AODA, and Pharmacy will not use or disclose your
health information without your permission, except as described in this notice
and as permitted by the HIPAA Privacy Regulations.
III. How Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy may use and disclose health information about
you.
The following categories describe how we may use and disclose
health information about you.
We will use and
disclose your health information to provide your treatment.
For
example: We may
disclose your personal health information to health care providers (doctors,
dentists, pharmacies, hospitals and other caregivers) who request it to aid in
your treatment.
If Red Cliff Community Health Center, Ambulance,
AODA, and Pharmacy staff sends you to another health care facility using
Contract Health Service (CHS), Red Cliff Community Health Center, Ambulance,
AODA, and Pharmacy will exchange your health information with that health care
provider for treatment decisions.
We will use and
disclose your health information for payment.
For
example: In
order to administer the programs and receive payment for services, the Red
Cliff Health Center, Ambulance, AODA, and Pharmacy must use and disclose your
health information to determine:
· Eligibility for Programs
· Payment for Services
If the Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy sends you to another health care facility using
Contract Health Service (CHS), Red Cliff Community Health Center, Ambulance,
AODA, and Pharmacy will exchange your health information with that provider for
health care payment decisions.
We will use your
health information for health care operations.
For
example: We may
use your health information to evaluate your care and outcomes. This
information will be used to continually improve the quality and effectiveness
of the services we provide. This includes health care services provided under
Contract Health Services (CHS).
Red Cliff Community
Health Center, Ambulance, AODA, and Pharmacy may use and disclose health
information about you without your consent or authorization for the following
purposes:
Required
by Law: We may
use or disclose your personal health information, as we are required to do so
by federal, state, or local law.
Communication
with Family: The Red Cliff Community Health Center, Ambulance, AODA, and
Pharmacy providers may disclose your health information to others as directed
by you. For example, we may inform your family members, relatives, close
personal friends or any other person you identify. This disclosure of health
information is relevant to that person’s involvement in providing care or
payment for services.
Research: Under
certain circumstances, and only after a special approval process, we may use
and disclose your health information to help conduct research. Such research
might try to find out whether a certain treatment is effective in curing an
illness and/or identifying of presence of disease within the community.
Death: We may disclose your health information to
coroners and medical examiners so they can carry out their duties related to
your death, such as identifying the body, determining the cause of death.
Organ Procurement
Organizations:
Consistent with applicable laws, the Red Cliff Community Health Center, Ambulance,
AODA, and Pharmacy may disclose health information to organ procurement
organizations or other entities engaged in the procurement, banking, or
transplantation of organs for the purpose of tissue donation and transplant.
Service Reminders: Red Cliff Community Health Center, Ambulance,
AODA, and Pharmacy may contact you to provide information about other types of
health-related benefits and services that may be of interest to you. Example:
We may contact you about the availability of new services for diabetes.
Appointment Reminders: The Red Cliff Community Health Center and AODA staff, for example,
may contact you with a reminder that you have an appointment for medical care
at our facilities.
Treatment
Alternatives: The Red Cliff Community Health Center and AODA
staff, may recommend possible treatment alternatives and options that may be of
interest to you, using your health information.
Food and Drug
Administration (FDA):
The Red Cliff Community Health Center, Ambulance, AODA, and Pharmacy may disclose
to the FDA your health information, if you have experienced adverse events with
food, supplements, product and product defects, or post marketing surveillance
information to enable product recalls, repairs, or replacement.
Public Health: The Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy will disclose, as required by law, your health
information to public health or legal authorities charged with preventing or
controlling disease, injury, or disability, charged with receiving reports of
child abuse or neglect, and charged with receiving information of abuse,
neglect, or domestic violence. The Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy may disclose your health information to an
individual who may have been exposed to a communicable disease or may otherwise
be at risk of contracting or spreading a disease or condition. We may have to
report certain work-related instances and injuries, to your employer so your
workplace can be monitored for safety.
Workers Compensation:
The Red Cliff
Community Health Center, Ambulance, AODA, and Pharmacy will disclose health
information for workers compensation or similar programs as required by law.
Correctional
Institution: Should
you be an inmate of a correctional institution, The Red Cliff Community Health
Center, Ambulance, AODA, and Pharmacy may disclose to the institution, health
information necessary for your health and the health and safety of other
individuals.
Law Enforcement: The Red Cliff Community Health Center, Ambulance,
AODA, and Pharmacy may disclose health information for law enforcement purposes
as required by law or in response to a court order.
Members of the
Military: If you
are a member of the military services or U.S. Public Health Service
Commissioned Corps, The Red Cliff Community Health Center, Ambulance, AODA, and
Pharmacy may disclose your health information to your military command
authorities.
Health Oversight
Authorities: The Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy may disclose health information to health
oversight authorities for activities authorized by law. These oversight
activities include investigations, audits, inspections, and other actions.
These are necessary for the government to monitor the health care system,
government programs, and monitor compliance with civil rights laws.
To avoid a serious
threat to health or safety: We may disclose your health information to the extent necessary to
avoid a serious and imminent threat to your health or safety or to the health
or safety of others.
Non Violation
of this Notice: Red Cliff Community Health Center, Ambulance, AODA, And Pharmacy is not
in violation of this Notice or the HIPAA Privacy Rule if any of its employees,
business associates or contractors discloses information under the following
circumstances: disclosures by whistleblowers and disclosures by workforce
member crime victims.
Note: Except for the situations listed above, we must
obtain your specific written authorization for any other release of your health
information. An authorization is different than consent. One primary difference
is that unlike with consents a provider must treat you even if you do not wish
to sign an authorization for. If you sign an authorization form, you may
withdraw your authorization at any time, as long as your withdrawal is in
writing. If you wish to withdraw your authorization, please submit your written
withdrawal to the Medical Records Department.
IV. Your Health
Information Rights
Although your health record is the physical property of the Red
Cliff Community Health Center, Ambulance, AODA, and Pharmacy, the information
belongs to you. All requests in connection with the following rights must be in
writing. You have the right to:
· Inspect and
copy your health information. With
a few exceptions, you have the right to inspect and obtain a copy of your
health information. The Health Center, Ambulance, AODA, and Pharmacy have the
right to grant access in whole, in part or to deny access. If a denial is based
on revisable grounds, the client has the right to request a review. The copying
fee is 10 cents per page after the first 10 pages.
· Request a
restriction on certain uses and
disclosures of your health information. The Red
Cliff Community Health Center, Ambulance, AODA, and Pharmacy are not required
to agree to any requested restriction.
· Request an amendment to your health record if you believe your health information is incorrect or incomplete; you
may ask us to amend the information.
· Request
confidential communications about your health information. You may request confidential communications by an alternate
means or at an alternate location. The Health Center, Ambulance, AODA, and
Pharmacy will accommodate all reasonable requests.
· Receive an accounting of
disclosures of your health information. You have the right to ask for an accounting of disclosures
of your health information we have made during the previous six years, but the
request cannot include those dated before April 14, 2003. The accounting of
disclosures must include the date of each disclosure, who received the
disclosed health information, a brief description of the health information
disclosed, and why the disclosure was made. The Health Center, Ambulance, AODA,
and Pharmacy may not charge you for the list, unless you request such list more
than once per year. In addition, we will not include in the list disclosures
made to you, or for purposes of treatment, payment, health care operations,
national security, law enforcement/corrections, and certain health oversight
activities.
· Obtain a paper copy of the Red Cliff Community Health
Center, Ambulance, AODA, and Pharmacy Notice of Privacy Practices upon request
To exercise
your rights under this Notice, to ask for more information, or to report
a problem you may
contact the Privacy Officer at:
Privacy
Officer Pauline Grooms
715-779-3707
Red Cliff Community Health Center
88455 Pike Road, P.O. Box 529
Bayfield, WI 54814
If you believe your privacy rights have been violated, you may
file a written complaint with the above individual or the Secretary of Health
and Human Services, U.S. Department of Health and Human Services, Washington,
DC 20201. There will be no retaliation for filing a complaint. You may file a
complaint at either entity.
Effective Date: April 14, 2003
Acknowledgment of Receipt
for
The Red Cliff Community
Health Services
Notice of Privacy Practices
I hereby acknowledge receipt of the Red Cliff
Community Health Services Notice of Privacy Practices at:
Red Cliff Community Health
Center
88455 Pike Road
PO Box 529
Bayfield, WI 54814
Signature of Client Date
Signature of Clients Representative Date
Acknowledgement of Receipt
Was Not Obtained:
The patient was provided the Privacy Notice and a
good faith effort was made to obtain the patient’s written acknowledgment. The
reason it was not obtained:
Personnel Signature Date
Policy and Procedure for
Providing
Red Cliff Community Health
Center, Ambulance,
AODA, and Pharmacy
Notice of Privacy Practices
45 CFR 164.520
Purpose: To establish policy and procedure for providing the Notice
of Privacy Practices to all clients.
POLICY: It is Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy policy to provide adequate notice of its uses and
disclosures of PHI and of the client’s rights and Red Cliff Community Health
Center’s, Ambulance, AODA, and Pharmacy legal duties with respect to PHI to its
clients.
PROCEDURE: The Red Cliff Community Health Center, Ambulance, AODA, and Pharmacy
shall prominently and clearly display the Notice of Privacy Practices in each
physical location.
Any
individual, whether or not a client, has the right to request and receive a
copy of the Red Cliff Community Health Center, Ambulance, AODA, and Pharmacy
Notice of Privacy Practices (“Notice”) at any time.
All
clients, including both new and established clients, shall be provided a copy
of the Notice at their first visit to the Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy after April 13, 2003, as follows:
The Patient Registration Office or other appropriate department
will provide a copy of the current Notice to the client.
The client does not have to read the Notice, instead alternate
means may be used, if requested, to communicate the content (e.g., a staff
member or accompanying family member may read the Notice to the client).
Ask the client to acknowledge receipt of the Notice by signing
the Acknowledgment of Receipt for the Red Cliff Community Health Center,
Ambulance, AODA, and Pharmacy Notice of Privacy Practices.
If another individual is acting as the client’s representative
in making healthcare decisions on behalf of the client, the individual should
provide the Red Cliff Community Health Center, Ambulance, AODA, and Pharmacy a
copy of Power of Attorney and/or other legal document where applicable. Once
that is provided that person acting on behalf of the client will receive the
Notice and the Acknowledgment. Once the client can resume making his or her own
decisions we will provide the client with the Notice and Acknowledgment form to
be updated at that time.
In the event of an emergency, the Privacy Notice must be
provided to the client when it is practical to do so after the emergency
situation has ended. This must be documented on the Acknowledgment of Receipt
Form.
In the event a client refuses to provide written Acknowledgment
of Receipt, document the refusal on the Acknowledgment of Receipt form.
If the Notice is revised by a material change, the revised Notice must be posted clearly and prominently in each physical location on or after the effective date of the revision.