Privacy Policy

NOTICE OF PRIVACY PRACTICES

 

Effective Date:  April 14, 2003
Revised: September 23, 2013

 

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.

Saint Alphonsus Health System (SAHS) is required by the Health Insurance Portability and Accountability Act of 1996, and the Health Information Technology for Economic and Clinical Health Act (found in Title XIII of the American Recovery and Reinvestment Act of 2009) (collectively referred to as “HIPAA”), as amended from time to time, 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 will only use or disclose your PHI as permitted or required by applicable state law.  This Notice applies to your PHI in our possession including the medical records generated by us.

Saint Alphonsus Health System 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 we will use and disclose your PHI.

This Notice applies to the delivery of health care by Saint Alphonsus Health System and its medical staffs in its main hospitals, outpatient departments and clinics.  This Notice also applies to the utilization review and quality assessment activities of CHE Trinity Health and Saint Alphonsus Health System as a member of CHE Trinity Health, a Catholic health care system with facilities located in multiple states throughout the United States.  

 

I.              Permitted Use or Disclosure

 

A.    Treatment:  Saint Alphonsus Health System will use and disclose your PHI to provide, coordinate, or manage your health care and related services to carry out treatment functions. The following are examples of how Saint Alphonsus Health System will use and/or disclose your PHI:

¨       To your attending physician, consulting physician(s), and other health care providers who have a legitimate need for such information in your care and continued treatment.

¨       To coordinate your treatment (e.g., appointment scheduling) with us and other health care providers such as name, address, employment, insurance carrier, etc.

¨       To contact you as a reminder that you have an appointment for treatment or medical care at our facilities.

¨       To provide you with information about treatment alternatives or other health-related benefits or services.

¨       If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Saint Alphonsus Health System will disclose your PHI to the correctional institution or law enforcement official.

B.   Payment:  Saint Alphonsus Health System will use and disclose PHI about you for payment purposes.  The following are examples of how Saint Alphonsus Health System will use and/or disclose your PHI:

¨       To an insurance company, third party payer, third party administrator, health plan or other health care provider (or their duly authorized representatives) for payment purposes such as  determining coverage, eligibility, pre-approval / authorization for treatment, billing, claims management, reimbursement audits, etc.

¨       To collection agencies and other subcontractors engaged in obtaining payment for care.

C.   Health Care Operations: Saint Alphonsus Health System will use and disclose your PHI for health care operations purposes.  The following are examples of how Saint Alphonsus Health System will use and/or disclose your PHI:

¨       For case management, quality assurance, utilization, accounting, auditing, population based activities relating to improving health or reducing health care costs, education, accreditation, licensing and credentialing activities of Saint Alphonsus Health System .

¨       To consultants, accountants, auditors, attorneys, transcription companies, information technology providers, etc.   

D.   Other Uses and Disclosures: As part of treatment, payment and health care operations, Saint Alphonsus Health System may also use your PHI for the following purposes:

¨       Fundraising Activities:  Saint Alphonsus Health System will use and may also disclose some of your PHI to a related foundation for certain fundraising activities.  For example, Saint Alphonsus Health System may disclose your demographic information, your treatment dates of service, treating physician information, department of service and outcomes information to the foundation who may ask you for a monetary donation.  Any fundraising communication sent to you will let you know how you can exercise your right to opt-out of receiving similar communications in the future.

¨       Medical Research:  Saint Alphonsus Health System will use and disclose your PHI without your authorization to medical researchers who request it for approved medical research projects.  Researchers are required to safeguard all PHI they receive.

¨       Information and Health Promotion Activities:  Saint Alphonsus Health System 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 general newsletter or specific information based on your own health concerns.

E.   More Stringent State and Federal Laws:  The State law of Idaho and Oregon is more stringent than HIPAA in several areas. Certain federal laws also are more stringent than HIPAA. Saint Alphonsus Health System will continue to abide by these more stringent state and federal laws. 

                          i.    More Stringent 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. 

                        ii.    More Stringent State Laws:  State law is more stringent when the individual is entitled to greater access to records than under HIPAA.  State law also is more restrictive when the records are more protected from disclosure by state law than under HIPAA.  In cases where Saint Alphonsus Health System provides treatment to a patient who resides in a neighboring state Saint Alphonsus Health System will abide by the more stringent applicable state law.

F.        Health Information Exchange: Saint Alphonsus Health System shares your health records electronically with Idaho Health Data Exchange (IHDE) for the purpose of improving the overall quality of health care services provided to you (e.g., avoiding unnecessary duplicate testing). The electronic health records will include sensitive diagnoses such as HIV/AIDS, sexually transmitted diseases, genetic information, and mental health substance abuse, etc.  The IHDE is functioning as our business associate and, in acting on our behalf, the IHDE will transmit, maintain and store your PHI for treatment, payment and health care operation purposes. The IHDE has a duty to implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of your medical information.  

You may request to have your information restricted to providers who participate in the IHDE by completing a Request to Restrict Disclosure form and submitting it directly to the IHDE by mail or fax.
Idaho Health Data Exchange
450 West State Street
P.O. Box 6978
Boise, ID 83707
Phone:  (208) 332-7253
Facsimile: (208) 332-7217
Email:  info@idahohde.org
http://www.idahohde.org/dsite/

II.            Permitted Use or Disclosure with an Opportunity for You to Agree or Object

A.   Family/Friends:  Saint Alphonsus Health System will disclose PHI about you to a friend or family member who is involved in or paying for your medical care.  You have a right to request that your PHI not be shared with some or all of your family or friends.  In addition, Saint Alphonsus Health System will disclose PHI about you to an agency assisting in disaster relief efforts so that your family can be notified about your condition, status, and location. 

B.   Saint Alphonsus Health System – Facility Directory:  Saint Alphonsus Health System will include certain information about you in facility directory while you are a hospital patient at Saint Alphonsus Health System. This information will include your name, location in Saint Alphonsus Health System, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation.  The directory information, except your religious affiliation, will be disclosed to people who ask for you by name.  You have the right to request that your name not be included in Saint Alphonsus Health System’s directory.  If you request to opt-out of the facility directory, we cannot inform visitors of your presence, location, or general condition.

C.   Spiritual Care:  Directory information, including your religious affiliation, will be given to a member of the clergy, even if they do not ask for you by name.  Spiritual care providers are members of the health care team at Saint Alphonsus Health System and may be consulted upon regarding your care.  You have the right to request that your name not be given to any member of the clergy. 

D.   Media Reports:  Saint Alphonsus Health System will release facility directory information to the media (excluding religious affiliation) if the media requests information about you using your name and after we have given you an opportunity to agree or object.

III.           Use or Disclosure Requiring Your Authorization

A.    Marketing:  Subject to certain limited exceptions, your written authorization is required in cases where Saint Alphonsus Health System receives any direct or indirect financial remuneration in exchange for making the communication to you which encourages you to purchase a product or service or for a disclosure to a third party who wants to market their products or services to you. 

B.    Research:  Saint Alphonsus Health System will obtain your written authorization to use or disclose your PHI for research purposes when required by HIPAA.

C.    Psychotherapy Notes:  Most uses and disclosures of psychotherapy notes require your written authorization. 

D.    Sale of PHI:  Subject to certain limited exceptions, disclosures that constitute a sale of PHI require your written authorization.

E.     Other Uses and Disclosures:  Any other uses or disclosures of PHI that are not described in this Notice of Privacy Practices require 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 or Required by Public Policy or Law without your Authorization

A.   Law Enforcement Purposes:  Saint Alphonsus Health System will disclose your PHI for law enforcement purposes as required by law, such as identifying a criminal suspect or a missing person, or providing information about a crime victim or criminal conduct. 

B. Required by Law:  Saint Alphonsus Health System will disclose PHI about you when required by federal, state or local law.  Examples include disclosures in response to a court order / subpoena, mandatory state reporting (e.g., gunshot wounds, victims of child abuse or neglect), or information necessary to comply with other laws such as workers’ compensation or similar laws. 

C.  Public Health Oversight or Safety:  The Saint Alphonsus Health System will use and disclose PHI to avert a serious threat to the health and safety of a person or the public.  Examples include disclosures of PHI to state investigators regarding quality of care or to public health agencies regarding immunizations, communicable diseases, etc.  Saint Alphonsus Health System 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 in product recalls, etc. 

D. Coroners, Medical Examiners, Funeral Directors:  Saint Alphonsus Health System 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. Saint Alphonsus Health System may also disclose your medical information to funeral directors as necessary to carry out their duties.

E. Organ Procurement:  Saint Alphonsus Health System will disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes. 

F.  Specialized Government Functions: Saint Alphonsus Health System will disclose your PHI regarding government functions such as military, national security and intelligence activities.  Saint Alphonsus Health System will use or disclose PHI to the Department of Veterans Affairs to determine whether you are eligible for certain benefits.

G.  Immunizations:  Saint Alphonsus Health System will disclose proof of immunization to a school where the state or other similar law requires it prior to admitting a student. 

V.         Your Health Information Rights

You have the following individual rights concerning your PHI:

A.   Right to Inspect and Copy:  Subject to certain limited exceptions, you have the right to access your PHI and to inspect and copy your PHI as long as we maintain the data. 

If Saint Alphonsus Health System denies your request for access to your PHI, Saint Alphonsus Health System will notify you in writing with the reason for the denial.  For example, you do not have the right to psychotherapy notes or to inspect the information which is subject to law prohibiting access.  You may have the right to have this decision reviewed. 

You also have the right to request your PHI in electronic format in cases where Saint Alphonsus Health System utilizes electronic health records.  You may also access information via patient portal if made available by Saint Alphonsus Health System

You will be charged a reasonable copying fee in accordance with applicable federal or state law. 

B.  Right to Amend:  You have the right to amend your PHI for as long as Saint Alphonsus Health System maintains the data.  You must make your request for amendment of your PHI in writing to Saint Alphonsus Health System, including your reason to support the requested amendment. 

However, Saint Alphonsus Health System will deny your request for amendment if: 

¨       Saint Alphonsus Health System 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); or

¨       The information is accurate and complete.

If Saint Alphonsus Health System denies your request for changes in your PHI, Saint Alphonsus Health System will notify you in writing with the reason for the denial.  Saint Alphonsus Health System will also inform you of your right to submit a written statement disagreeing with the denial.  You may ask that Saint Alphonsus Health System include your request for amendment and the denial any time that Saint Alphonsus Health System subsequently discloses the information that you wanted changed.  Saint Alphonsus Health System may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.

C.   Right to an Accounting:  You have a right to receive an accounting of the disclosures of your PHI that Saint Alphonsus Health System has 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; or

¨       To correctional institutions or law enforcement officials.

You must make your request for an accounting of disclosures of your PHI in writing to Saint Alphonsus Health System. 

You must include the time period of the accounting, which may not be longer than 6 years. In any given 12-month period, Saint Alphonsus Health System will provide you with an 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 health care operations functions or to prohibit such disclosure.  However, Saint Alphonsus Health System will consider your request but is not required to agree to the requested restrictions.

E.   Right to Request Restrictions to a Health Plan:  You have the right to request a restriction on disclosure of your PHI to a health plan (for purposes of payment or health care operations) in cases where you paid out of pocket, in full, for the items received or services rendered. 

F. 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 Saint Alphonsus Health System only contact you at work or by mail.

G.  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.

VI.        Breach of Unsecured PHI

If a breach of unsecured PHI affecting you occurs, Saint Alphonsus Health System is required to notify you of the breach. 

VII.                         Sharing and Joint Use of Your Health Information

In the course of providing care to you and in furtherance of Saint Alphonsus Health System’s mission to improve the health of the community, Saint Alphonsus Health System 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 staffs of Saint Alphonsus Health System hospitals participate in an organized health care arrangement to deliver health care to you.  Both Saint Alphonsus Health System and all the respective hospital medical staffs have agreed to abide by the terms of this Notice with respect to PHI created or received as part of delivery of health care to you by Saint Alphonsus Health System.  Physicians and allied health care professionals who are members of Saint Alphonsus Health System’s medical staffs will have access to and use your PHI for treatment, payment and health care operations purposes related to your care within Saint Alphonsus Health System.  Saint Alphonsus Health System will disclose your PHI to the medical staffs for treatment, payment and health care operations. 

B.   Membership in CHE Trinity Health.  Saint Alphonsus Health System and members of CHE Trinity Health participate together in an organized health care arrangement for utilization review and quality assessment activities.  We have agreed to abide by the terms of this Notice with respect to PHI created or received as part of utilization review and quality assessment activities of CHE Trinity Health and its members. Members of CHE Trinity Health will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or health care operations.

As a part of CHE Trinity Health, a national Catholic health care system, Saint Alphonsus Health System and other hospitals, nursing homes, and health care providers in CHE Trinity Health share your PHI for utilization review and quality assessment activities of CHE Trinity Health, the parent company, and its members. Members of CHE Trinity Health also use your PHI for your treatment, payment to Saint Alphonsus Health System and/or for the health care operations permitted by HIPAA with respect to our mutual patients. 

Please go to CHE Trinity Health’s websites for a listing of member organizations at http://www.trinity-health.org/ and http://www.che.org/.  Or, alternatively, you can call Saint Alphonsus Health System’s Privacy Official to request the same.

C.   Business Associates. Saint Alphonsus Health System will share your PHI with business associates and their Subcontractors contracted to perform business functions on Saint Alphonsus Health System’s behalf, including CHE Trinity Health which performs certain business functions for Saint Alphonsus Health System. 

VIII.        Changes to this Notice.  Saint Alphonsus Health System will abide by the terms of the Notice currently in effect. Saint Alphonsus Health System reserves the right to make material changes to the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. Saint Alphonsus Health System will distribute / provide you with a revised Notice at your first visit following the revision of the Notice in cases where it makes a material change in the Notice. You can also ask Saint Alphonsus Health System for a current copy of the Notice at any time.

IX.          Complaints. If you believe your privacy rights have been violated, you may file a complaint with Saint Alphonsus Health System’s Privacy Official or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing directly to Saint Alphonsus Health System’s Privacy Official. Saint Alphonsus Health System assures you that there will be no retaliation for filing a complaint. You will not be retaliated against for filing any complaint. 

X.            Privacy Official – Questions / Concerns / Additional Information. If you have any questions, concerns, or want further information regarding the issues covered by this Notice of Privacy Practice or seek additional information regarding Saint Alphonsus Health System’s privacy policies and procedures, please contact Saint Alphonsus Health System’s Privacy Official at:

Saint Alphonsus Regional Medical Center – Boise
Attn:  Privacy Officer
1055 N. Curtis Road
Boise, Idaho 83706

 

Saint Alphonsus Medical Center – Nampa
Attn:  Privacy Officer
1512 12th Avenue Road
Nampa, ID 83686

 

Saint Alphonsus Medical Center – Ontario
Attn:  Privacy Officer
351 S.W. 9th Street
Ontario, OR 97914

 

Saint Alphonsus Medical Center – Baker City
Attn:  Privacy Officer
3325 Pocahontas Road
Baker City, OR 97814