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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AS WELL AS HOW YOU CAN ACCESS THIS
INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact our
Privacy Officer at (502)426-6380 for KMI or (502)896-0495 for
Dupont .
OUR PLEDGE REGARDING PROTECTED
MENTAL HEALTH INFORMATION
This notice describes our healthcare system's practices and that
of all persons employed or contracted by Ten Broeck Healthcare
System.
We understand that your mental health information is personal
and confidential, and we pledge that we will protect this
information about you. We will create a record of the care
and services you receive at Ten Broeck in order to provide you with
quality care and to comply with certain legal requirements.
This notice applies to all of the records of your care generated by
the healthcare system.
We are required by law to:
- make sure that medical information that identifies you is kept
private;
- give you this notice of our legal duties and privacy practices
with respect to your protected health information; and
- follow the terms of this notice.
HOW WE MAY USE AND DISCLOSE
MEDICAL INFORMATION ABOUT YOU
Due to the confidentiality of your mental health and/or chemical
dependency information, Ten Broeck Healthcare Systems will only
disclose information regarding your treatment upon receiving a
proper authorization from you. Exceptions include when the
information is needed for treatment, payment, or healthcare
operations as well as when required by federal, state, or local
law.
For Treatment: We may use medical information about you to
provide you with medical treatment or services. We may
disclose medical information about you to doctors, nurses,
technicians, healthcare students, clergy, or others who are
involved in your care. Different departments of the
healthcare system may share medical information about you in order
to coordinate the different services you need. We may
disclose information to persons outside the hospital involved in
continuing your care (i.e., assisting you in scheduling follow-up
appointments) so long as you have given us authorization to do
so.
For Payment: We may use and disclose medical information about
you so that the treatment and services provided to you by the
healthcare system may be billed. Payment may be collected
from you, and insurance company, or a third party. We may
need to give your health plan information about your treatment in
order for your health plan to pay us or to reimburse you. We
may also tell your health plan about treatment you are going to
receive to obtain prior approval or to determine if your plan will
cover the treatment.
For Healthcare Operations: We may use and disclose medical
information about you for healthcare system operations.
Information used in this sense may be to analyze the services we
provide, to evaluate staff performance, and for educational
purposes.
Fund-raising Activities. The hospital, or a foundation
related to the hospital, may use information about you in an effort
to raise money for the hospital and its operations. This
information would include your name, address, phone number, and the
dates you received treatment or services. If you do not want
the system to contact you for fund-raising efforts, you must notify
our Privacy Officer in writing.
SPECIAL SITUATIONS
Research and Health-Related Alternatives: Under certain
circumstances, we may use and disclose medical information about
you for research purposes, notification of treatment alternatives,
and/or health-related benefits and services. We will remove
information that identifies you from this set of medical
information in order to protect your identity. We will ask
for your specific permission if the situation would require access
to your name, address or other information that reveals who you
are.
Organ and Tissue Donation: If you are an organ donor, we may
release medical information as necessary to facilitate organ or
tissue donation and transplantation.
Workers' Compensation: We may release medical information about
you to for workers' compensation or similar programs upon receipt
of a proper written authorization from you or as required by
law.
Reporting Public Health Risks: We may use and disclose medical
information about you to agencies when required by law to prevent a
serious threat to the health and safety of you or another person.
Examples of such situations include:
- to prevent or control disease, injury or disability,
- to report births and deaths;
- to report abuse and/or neglect;
- to report reactions to medications or problems with
products.
Health Oversight Activities: We may disclose medical information
to a health oversight agency for activities authorized by law.
These include, for example, audits, investigations,
inspections, and licensure. These activities are necessary
for the government to monitor the healthcare system, government
programs, and compliance with civil rights laws.
Coroners and Medical Examiners: We may release medical
information to a coroner or medical examiner. This may be
necessary to identify a deceased person or determine the cause of
death.
Legal Disclosures: If you are involved in a lawsuit or a legal
dispute, we may disclose medical information about you in response
to a court or administrative order which has been signed by a judge
or such person given equal authority under the law.
Government/Law Enforcement Agencies: We will disclose medical
information about you when required to do so by federal, state, or
local law.
Military:
- Members of the armed forces - we may release medical
information about you as required by military command
authorities.
- Foreign military personnel - we may release medical information
about you to the appropriate foreign military authority.
We may release medical information about you:
- If asked to do so by a law enforcement official in response to
a court order which has been signed by a judge and in certain cases
involving emergencies, criminal activities, missing persons, and
death.
- When it is requested by authorized federal officials for
intelligence, counterintelligence, and other national security
activities authorize by law including, but not limited to, the
protection of the President, other authorized persons, or foreign
heads of state, or conduct special.
- To the correctional institution or law enforcement official if
you are an inmate of a correctional institution or are under the
custody of a law-enforcement official.
Other Uses of Medical Information: Other uses and
disclosures of medical information not covered by this notice or
the laws that apply to us will be made only with your written
permission.
Changes to This Notice: We reserve the right to change this
notice. We reserve the right to make the revised notice
effective for medical information we already have about you as well
as any information we receive in the future. The effective
date of the notice will be located on the first page in the top
right-hand corner.
You have the following rights regarding the medical information
we maintain about you:
- The right to review your records or receive a copy of your
records at any time. You will be asked to complete a written
authorization in order to facilitate your request. We do
have the right to deny your request under certain circumstances.
- The right to make a written request to amend the information
contained within your medical record if you feel the information is
incorrect or incomplete. The request must provide a reason
that supports your request.
We do have the right to deny your request for any of the
following:
- Failure to make the request in writing;
- Failure to include a reason to support the request;
- If the information was not created by us and the entity that
created is availableto make the amendment;
- If the request is to amend information not:
a) part of the medical records kept by or for the healthcare
system, or
b) part of the record you would be permitted to inspect and
copy.
- If the information you are requesting to amend is accurate and
complete.
- The right to receive an accounting of certain disclosures we
have made, if any, of your protected health information.
- The right to restrict certain parties from receiving your
medical information; however, the healthcare system is not required
to agree to the restriction.
- The right to receive confidential communication regarding your
protected health information.
- The right to revoke any authorization to release medical
information about you. The revocation must be in writing and will
not include any information the healthcare system disclosed prior
to receiving the written revocation.
- The right to receive a copy of this privacy notice at any time
by requesting a copy from any of our system personnel.
COMPLAINTS
If you believe your privacy rights have been violated, you may
submit your complaint in writing to the Privacy Officer at the
following addresses. KMI: 8521LaGrange Road, Louisville, KY
40242 or Dupont: 1405 Browns Lane, Louisville, KY 40207.
If we cannot resolve your concern, you also have the right to
file a written complaint with the Secretary of the Department of
Health and Human Services.
The quality of your care will not be jeopardized nor will you be
penalized for filing a complaint.
TEN BROECK HEALTHCARE SYSTEM
Effective 4/14/03
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