Notice of Privacy Practices
Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW CAREFULLY.
We at Saint Joseph Regional Medical Center, Inc. (SJRMC), are required by law and our mission to maintain the privacy of individually identifiable patient health information (this information is protected health information and is referred to herein as PHI). We are also required to provide patients with a Notice of Privacy Practices regarding PHI. We are required to post this Notice of Privacy Practices in a prominent place within all of our facilities. We will only use or disclose your PHI as permitted or required by applicable state law. This Notice of Privacy Practices applies to your PHI in our possession including the medical records generated by us.
SJRMC understands that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how SJRMC will use and disclose your PHI. This Notice of Privacy Practices applies to the delivery of healthcare by SJRMC and its medical staff in our hospitals, outpatient departments, clinics, physician offices, home care and all of our other facilities.
This Notice of Privacy Practices also applies to the utilization review and quality assessment activities of Trinity Health and SJRMC as a member of Trinity Health, a Catholic healthcare system with facilities in seven states.
I. Permitted use or disclosure
A. Treatment: SJRMC will use and disclose your PHI in the provision and coordination of healthcare to carry out treatment functions.
SJRMC will disclose all or any portion of your patient medical record information to your attending physician, consulting physician(s), nurses, technicians, medical students and other health care providers who have a legitimate need for such information in your care and continued treatment.
SJRMC is a not-for-profit, Catholic sponsored healthcare provider. Spiritual care providers are members of our care staff and will be a part of SJRMC's team of care providers who use your medical information to provide healthcare services to you when you are in SJRMC's facilities.
Different SJRMC departments will share medical information about you in order to coordinate specific services, such as lab work, x-rays and prescriptions.
SJRMC also will disclose your medical information to people or entities outside SJRMC who will be involved in your medical care after you leave SJRMC, such as family members, clergy and others who will provide services that are part of your care.
SJRMC will share certain information such as your name, address, employment, insurance carrier, emergency contact information and appointment scheduling information in an effort to coordinate your treatment with other SJRMC providers and with other healthcare providers.
SJRMC will use and disclose your PHI to inform you of or recommend possible treatment options or alternatives that will be of interest to you.
SJRMC will use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at SJRMC.
If you are an inmate of a correctional institution or under the custody of a law enforcement officer, SJRMC will disclose your PHI to the correctional institution or law enforcement official.
B. Payment: SJRMC will disclose PHI about you for the purposes of determining coverage, eligibility, funding, billing, claims management, medical data processing, stop loss/reinsurance and reimbursement.
The medical information will be disclosed to an insurance company, third party payer, third party administrator, health plan or other healthcare provider (or their duly authorized representatives) involved in the payment of your medical bill and will include copies or excerpts of your medical records which are necessary for payment of your account. It will also include sharing the necessary information to obtain pre-approval for payment for treatment from your health plan.
SJRMC will disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.
C. Health care operations: SJRMC will use and disclose your PHI during routine healthcare operations including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of SJRMC, and for educational purposes.
For instance, SJRMC will need to share your demographic information, diagnosis, treatment plan and health status for population-based activities relating to improving health or reducing healthcare costs, protocol development, case management and care coordination, and contacting healthcare providers and patients with information about treatment alternatives in order for us to operate our business in an efficient, safe and legal manner.
D. Other uses and disclosures: As part of treatment, payment and healthcare operations, we may also use your PHI for the following purposes:
Fundraising activities: SJRMC will use and may also disclose some of your PHI to a related foundation for certain fundraising activities. For example, SJRMC will use your demographic information (e.g., name, address and other contact information, age, gender and insurance status) and the dates SJRMC provided service to you. Any communication sent to you will let you know how you may opt out of receiving similar communications in the future. SJRMC may disclose limited PHI to a company contracted to conduct fundraising for SJRMC. This company will use your PHI only for the purposes of fundraising for SJRMC. (If you wish to opt out, you may do so by contacting the organizational privacy officer at (574) 247-8765.)
Medical research: SJRMC may disclose your PHI without your authorization to medical researchers who request it for approved medical research projects; however, with very limited exceptions such disclosures must be cleared through a special approval process before any PHI is disclosed to the researchers. Researchers will be required to safeguard the PHI they receive.
Information and health promotion activities: SJRMC will use and disclose some of your PHI for certain health promotion activities. For example, your name and address will be used to send you newsletters or general communications. SJRMC will also send you information based on your own health concerns. SJRMC may send you this information if it has determined that a product or service may help you. The communication will explain how the product or service relates to your well being and can improve your health.
E. More stringent state and federal laws: The state law of Indiana is more stringent than the Health Insurance Portability and Accountability Act's privacy regulations (HIPAA) in several areas. State law is more stringent when the individual is entitled to greater access to records than under HIPAA and when under state law the records are more protected from disclosure than under HIPAA. Certain federal laws also are more stringent than HIPAA. SJRMC will continue to abide by these more stringent state and federal laws. The federal laws include applicable Internet privacy laws, such as the Children's Online Privacy Protection Act and the federal laws and regulations governing the confidentiality of health information regarding substance abuse treatment.
In Indiana a patient is not entitled to obtain their hospital records while they are still in the inpatient setting of hospital or other health facilities. SJRMC may disclose a health record to another healthcare provider, to a nonprofit medical research organizational or Indiana hospital trade organization to be used in connection with a scientific, statistical or education project. Pharmacists must provide greater protection regarding all prescriptions, drug orders, records and patient information. All of Indiana's state laws regarding its consent requirement continue to apply. Indiana law also allows the disclosure of PHI regarding the following specific conditions: birth defects, cancer, communicable diseases (including HIV/AIDS), genetic information, mental health records and substance abuse.
II. Permitted use or disclosure with an opportunity for you to agree or object
A. Family/friends: SJRMC's will disclose PHI about you to a friend or family member who is involved in your medical care. SJRMC will also give information to someone who helps you pay for your care. In addition, SJRMC will disclose PHI about you to an agency assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You have a right to request that your PHI not be shared with some or all of your family or friends.
B. SJRMC directory: SJRMC will include certain limited information about you in SJRMC's directory while you are a hospital patient at SJRMC. This information will include your name, location in SJRMC, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation. This is so your family and friends can visit you in SJRMC and know how you are doing. The directory information, except for your religious affiliation, will also be disclosed to people who ask for you by name.
You have the right to request that your name not be included in the SJRMC's Directory. If you request to opt out of the SJRMC's directory, we cannot inform visitors of your presence, location or general condition. SJRMC generally discloses a patient's death and contact information about funeral arrangements in response to a directory inquiry after the patient's next of kin have been notified.
C. Spiritual care: Directory information including your religious affiliation will be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. Your name, location and general condition will be disclosed to members of the religious community. It is our policy to notify your local religious organization by disclosing your name that you are in SJRMC and your condition. A chaplain from the Center for Spiritual Care at SJRMC may be called in to consult regarding your care. Chaplains are members of the healthcare team at SJRMC. You have a right to request that your name not be given to any member of the clergy.
D. Promotional communications: SJRMC does not share or sell your PHI to companies that market healthcare products or services directly to consumers for use by those companies to contact you, such as drug companies. SJRMC does maintain a database of individuals for promotional communications, disease management, health promotion and fundraising purposes. This database includes individuals to whom SJRMC may have sent health improvement materials and news about SJRMC previously and also individuals who have donated to SJRMC or who have expressed an interest in donating to SJRMC or other health-related activities. You may be included in this database. SJRMC sends information to the individuals in this database about the programs and services of SJRMC. If you wish to be deleted from this database, you may notify the privacy official of SJRMC at (574) 247-8765.
E. Media conditions reports: SJRMC may release information for an update to the media if the media requests information about you using your full name and after we have given you an opportunity to agree or object. The following information may then be disclosed: your condition described in general terms that do not communicate specific medical information, such as "undetermined", "good", "fair", "serious" or "critical".
III. Use or disclosure requiring your authorization
A. Marketing: SJRMC is not permitted to provide your PHI to any other person or company for marketing to you of any products or services other than SJRMC's products or services unless you have signed an authorization.
B. Research: SJRMC will use or disclose your PHI as part of research that includes providing you with treatment. For example, if you are part of a research study that includes treatment, SJRMC may require that you sign an authorization to allow the researchers to use or disclose your PHI for this research.
C. Other uses: Any uses or disclosures that are not for treatment, payment or operations and that are not permitted or required for public policy purposes or by law will be made only with your written authorization. Written authorizations will let you know why we are using your PHI. You have the right to revoke an authorization at any time.
IV. Use or disclosure permitted by public policy or law without your authorization
A. Law enforcement purposes: SJRMC will disclose your PHI for law enforcement purposes as required by law, such as responding to a court order or subpoena, identifying a criminal suspect or a missing person, or providing information about a crime victim or criminal conduct.
B. Required by law: SJRMC will disclose PHI about you when required by federal, state or local law to make reports or other disclosures. SJRMC also will make disclosures for judicial and administrative proceedings such as lawsuits or other disputes in response to a court order or subpoena. SJRMC will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violence. SJRMC will report drug diversion and information related to fraudulent prescription activity to law enforcement and regulatory agencies. Specialized government functions will warrant the use and disclosure of PHI. These government functions will include military and veteran's activities, national security and intelligence activities, and protective services for the president and others. SJRMC will make certain disclosures that are required in order to comply with workers' compensation or similar programs.
C. Coroners, medical examiners and funeral directors: SJRMC will disclose your PHI to a coroner or medical examiner. For example, this will be necessary to identify a deceased person or to determine a cause of death. SJRMC will also disclose your medical information to funeral directors as necessary to carry out their duties.
D. Organ procurement: SJRMC will disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes, as required by the state law of Indiana.
E. Health or safety: SJRMC will use and disclose PHI to avert a serious threat to health and safety of a person or the public. SJRMC will use and disclose PHI to public health agencies for immunizations, communicable diseases, etc. SJRMC will use and disclose PHI for activities related to the quality, safety or effectiveness of FDA-regulated products or activities, including collecting and reporting adverse events, tracking and facilitating product recalls, etc. and post marketing surveillance. Any patient receiving a medical device subject to FDA tracking requirements may refuse to disclose, or refuse permission to disclose, their name, address, telephone number and social security number, or other identifying information for the purpose of tracking.
V. Your health information rights
Although we at SJRMC must maintain all records concerning your hospitalization and treatment by SJRMC, you have the following rights concerning your PHI:
A. Right to inspect and copy: You have the right to access your PHI and to inspect and copy your PHI as long as we maintain it except for: psychotherapy notes, information that will be used in a civil, criminal or administrative action or proceeding, if SJRMC reasonably determines that the information requested is detrimental to the patient's physical or mental health or is likely to cause the patient to harm himself/herself or another individual and where prohibited or protected by law. SJRMC will deny your request for access to your PHI without giving you an opportunity to review that decision if:
- You don't have the right to inspect the information; or it is otherwise prohibited or protected by law.
- You are an inmate at a correctional institution and obtaining a copy of the information would risk the health, safety, security, custody or rehabilitation of you or other inmates.
- The disclosure of the information would threaten the safety of any officer, employee or other person at the correctional institution or who is responsible for transporting you.
- You are involved in a clinical research project and SJRMC created or obtained the PHI during that research. Your access to the information will be temporarily suspended for as long as the research is in progress.
- SJRMC obtained the information that you seek access to from someone other than the health care provider under a promise of confidentiality and your access request is likely to reveal the source of the information.
Under other limited circumstances. In these instances, however, SJRMC will allow the review of its decision by a healthcare professional that SJRMC has chosen. This person will not have been involved in the original decision to deny your request.
You agree to pay a reasonable copying charge. You must make your requests to access and copy your PHI in writing to SJRMC. SJRMC will respond to your request within 30 days of its receipt. If SJRMC cannot, SJRMC will notify you in writing to explain the delay and the date by which we will act on your request. In any event, SJRMC will act on your request within 60 days of its receipt.
B. Right to request an amendment: You have the right to request an amendment of your PHI for as long as SJRMC maintains it. However, SJRMC will deny your request for amendment if:
- SJRMC did not create the information.
- The information is not part of the designated record set.
- The information would not be available for your inspection (due to its condition or nature).
- The information is accurate and complete.
If SJRMC denies your request for changes in your PHI, SJRMC will notify you in writing with the reason for the denial. SJRMC will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that SJRMC include your request for amendment and the denial any time that SJRMC discloses the information that you wanted changed. SJRMC may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.
You must make your request for amendment of your PHI in writing to SJRMC, including your reason to support the requested amendment. SJRMC will respond to your request within 60 days of its receipt. If SJRMC cannot, SJRMC will notify you in writing to explain the delay and the date by which SJRMC will act on your request. In any event, SJRMC will act on your request within 90 days of its receipt.
C. Right to an accounting: You have a right to receive an accounting of the disclosures of your PHI that SJRMC made, except for the following disclosures:
- To carry out treatment, payment or health care operations.
- To you.
- To persons involved in your care.
- For national security or intelligence purposes.
- To correctional institutions or law enforcement officials.
- That occurred prior to April 14, 2003.
For each disclosure, you will receive: the date of the disclosure, the name of the receiving organization and address if known, a brief description of the PHI disclosed and a brief statement of the purpose of the disclosure or a copy of the written request for the information, if there was one.
You must make your request for an accounting of disclosures of your PHI in writing to SJRMC. You must include the time period of the accounting, which may not be longer than six years. SJRMC will respond to your request within 60 days from its receipt. If SJRMC cannot, SJRMC will notify you in writing to explain the delay and the date by which SJRMC will act on your request. In any event, SJRMC will act on your request within 90 days of its receipt.
In any given 12-month period, SJRMC will provide you with one accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting within that time period will be subject to a reasonable fee for preparing the accounting.
D. Right to request restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or healthcare operations functions or to prohibit such disclosure. SJRMC will consider your request but is not required to agree to the requested restrictions.
You also have an additional right to limit the release of PHI to family, friends or in the SJRMC directory. For example, you may ask that your name not be used in the waiting room or that information about your expected discharge date not be shared with your family.
E. Right to confidential communications: You have the right to receive confidential communications of your PHI by alternative means or at alternative locations. For example, you may request that SJRMC only contact you at work or by mail.
F. Right to receive a copy of this notice: You have the right to receive a paper copy of this Notice of Privacy Practices, upon request.
If you believe your privacy rights have been violated, you may file a complaint with SJRMC or with the Secretary of the Department of Health and Human Services. To file a complaint with SJRMC, please contact SJRMC's organizational privacy officer at (574) 247-8765. All complaints must be submitted in writing directly to SJRMC's organizational privacy officer. SJRMC assures you that there will be no retaliation for filing a complaint.
VII. Sharing and joint use of your protected health information
In the course of providing care to you and in furtherance of SJRMC's mission to improve the health of the community, SJRMC will share your PHI with other organizations as described below who have agreed to abide by the terms described below:
A. Medical staff: The medical staff and SJRMC participate together in an organized health care arrangement to deliver healthcare to you at SJRMC. Both SJRMC and its medical staff have agreed to abide by the terms of this Notice of Privacy Practices with respect to PHI created or received as part of delivery of healthcare services to you in SJRMC. Physicians and allied healthcare providers are members of SJRMC's medical staff and will have access to and use your PHI for treatment, payment and healthcare operations purposes related to your care within SJRMC. SJRMC will disclose your PHI to the medical staff for payment, treatment and healthcare operations.
B. Business associates: SJRMC will use and disclose your PHI to business associates contracted to perform business functions on its behalf including Trinity Health, SJRMC's parent company who performs certain business functions for SJRMC. Whenever an arrangement between SJRMC and another company involves the use or disclosure of your PHI, that business associate will be required to keep your information confidential.
C. Membership in Trinity Health: SJRMC, members of Trinity Health and Trinity Health participate together in an organized healthcare arrangement for utilization review and quality assessment activities. We have agreed to abide by the terms of this Notice of Privacy Practices with respect to PHI created or received as part of utilization review and quality assessment activities of Trinity Health and its members. Members of Trinity Health will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or healthcare operations. As a part of Trinity Health, a national Catholic healthcare system, SJRMC and other hospitals, nursing homes, and healthcare providers in Trinity Health share your PHI for utilization review and quality assessment activities of Trinity Health, the parent company and its members. Members of Trinity Health also use your PHI for your treatment, payment to SJRMC and/or for the healthcare operations permitted by HIPAA with respect to our mutual patients.
D. Affiliations: SJRMC is affiliated with the following healthcare organizations in which SJRMC is a co-owner:
- Advantage Health Solutions, Inc.
- Alick's Home Medical, Inc.
- Edison Lakes Imaging, LLC
- Michiana Health Information Network, LLC
- Northern Indiana Magnetic Resonance Imaging
- Occupational Health Network, LLC
- Sagamore Health Network, Inc.
- Select Communities, Inc.
- Select Health Network, Inc.
- Select Medical Management, LLC
- XRC Medical Imaging, LLC
- SJRMC will share your PHI with these organizations for purposes of your treatment, payment and healthcare operations by these organizations.
VIII. Additional information
For further information regarding the issues covered by this Notice of Privacy Practice, please contact: organizational privacy officer, Saint Joseph Regional Medical Center, Inc., Attn: Privacy Officer, 5215 Holy Cross Parkway, Mishawaka, Indiana, 46545 or 574.335.5000.
IX. Changes to this Notice of Privacy Practices
SJRMC will abide by the terms of the Notice of Privacy Practices currently in effect. SJRMC reserves the right to change the terms of its Notice of Privacy Practices and to make the new Notice of Privacy Practices provisions effective for all PHI that it maintains. SJRMC will provide you with the revised Notice of Privacy Practices at your first visit following the revision of the Notice of Privacy Practices.