Technical Information

Privacy Practices

Effective 04/14/2003

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 Will Follow This Notice:

This notice describes our Hospital's practices and that of:

Any health care professional authorized to enter information into your Hospital chart.
All departments, clinics, and units of the Hospital.
Any member of a volunteer group we allow to help you while you are at the Hospital.
All employees, staff, and other Hospital personnel.

II. Understanding Your Health Record/Information

Each time you visit the Hospital, a record of your visit is made. Typically this record contains your symptoms, examination and test results, diagnoses, treatment and plan for future care and treatment. This information, often referred to as your health or medical record, serves as:

  • A basis for planning your care and treatment.
  • A means of communication among the health professionals who contribute to your care.
  • A legal document describing the care you received.
  • A means by which you or a third party payer can verify that services billed were actually provided.
  • A tool in educating health professionals.
  • A source of data for medical research.
  • A source of information for public health officials who oversee the delivery of health care in the United States.
  • A source of data for facility planning and marketing.
  • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
  • Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, where, and why others may access your health information and make informed decisions when authorizing disclosure to others.

III. The Hospital's Responsibility

The Hospital is required to:

  • Maintain the privacy of your health information.
  • Provide you with a notice of our legal duties and privacy practices with respect to information we collect and maintain for you.
  • Abide by the terms of this notice.
  • Notify you if we are unable to agree to a requested restriction.
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

IV. How the Hospital Will Use or Disclose Your Health Information

The Hospital will not use or disclose your health information without your authorization, except as described in this notice. You have the opportunity to agree or object to the use or disclosure of either part or all of your Protected Health Information. If you are not present, or able to agree or object to the use or disclosure of the Protected Health Information, then your physician may use professional judgment to determine whether the disclosure is in your best interest. In this case, only the Protected Health Information that is relevant to your health care will be disclosed.

Treatment - We may use health information about you to provide medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students or other Hospital personnel who are involved in taking care of you at the Hospital. For example, information obtained by a health care practitioner will be recorded in your record and used to determine the course of treatment that should work best for you. Your health care team will also record his or her expectations, and they will then record the actions they took and their observations. Your physician will then use the information to know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you're discharged from our facility.

Payment - We may use and disclose health information about you so that the treatment and services you receive at the Hospital may be billed for and payment may be collected from you, an insurance company or a third party. The information accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used. For example, a bill may be sent to you or a third-party payer, including Medicare and Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Health Care Operations - We may use and disclose health information about you for regular Hospital operations. This information may be used to assess the care and outcomes in your care and others like it. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, health care students and other Hospital personnel for review and learning purposes.

Facility Directory - Unless you object, we will use and disclose your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation in our facility directory. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Members of the clergy will only be given your religious affiliation.

Individuals involved in your care or payment for your care
- We may release health information about you to a family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family may be notified about your condition, status and location.

Research - We may disclose information to researchers when their research proposal, research and protocols have been approved by the Hospital's Institutional Review Board.

Treatment Alternatives and Services - We may use and disclose health information to tell you about, or recommend possible treatment options or alternatives that may be of interest to you.

Fund-Raising - We may use health information about you to contact you in an effort to raise money for the Hospital and its operations. We may disclose demographic information to a foundation related to the Hospital so that the foundation may contact you in raising money for the Hospital.

As Required by Law - We may disclose health information for law enforcement purposes as required by federal, state or local law or in response to a valid subpoena. You will be notified, as required by law, of any such uses or disclosures.

Public Health - As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Communicable Diseases - We may disclosure your Protected Health Information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Abuse or Neglect - We may disclose your Protected Health Information to a public health authority that is authorized by law to receive reports of child abuse or neglect. The disclosure will be made consistent with the requirement of applicable federal and state laws.

V. Special Situations

Donor and Tissue Donations - If you are an organ donor, we may release health information to an organization that handles organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans - If you are a member of the armed forces, we may release health information about you as required by military command authorities.

Food and Drug Administration - We may disclose health information to the FDA that is relative to adverse events with respect to food, drugs, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.

Medical Examiners and Funeral Directors - We may disclose health information to funeral directors and/or medical examiners to carry out their duties consistent with applicable law.

Workers' Compensation - We may disclose health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Correctional Institution - Should you be an inmate of a correctional institution we may disclose health information necessary for your health, and health and safety of other individuals, to the institution or agents.

Health Oversight - We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government regulatory programs and civil rights laws.

Business Associates - We will share your Protected Health Information with third party "Business Associates" that perform various activities (e.g. billing, transcription services, MRI services) for the Hospital. Whenever an arrangement between the Hospital and a business associate involves the use or disclosure of your Protected Health Information, we will have a written contract that contains terms that protect the privacy of your Protected Health Information.

Criminal Activity
- Consistent with applicable federal and state laws we may disclose your Protected Health Information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose Protected Health Information if it is necessary for law enforcement authorities to identify or apprehend an individual.

VI. Your Health Information Rights

Although your medical record is the physical property of the Hospital, the information in your medical record belongs to you. You have the following rights:

Right to Restrictions
- You may ask us not to use or disclose any part of your Protected Health Information for the purposes of treatment, payment or operations. You may also request that any part of your Protected Health Information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this notice. Your request must be made in writing and on the appropriate form that will be provided for you at your request. You may request this form from any Hospital staff member who will contact the Privacy Officer, or you may directly contact the Privacy Officer at 751-5762. For more information about this right see, 45 code of Federal Regulations (C.F.R.) 164.522(a).

The Right to Inspect and Obtain Copies of Health Information - about you will be provided to you in the time frames established by the Hospital. The request must be made in writing to the Holy Cross Hospital Medical Records Department. Your request to inspect and copy may be denied in certain very limited circumstances. You may request that the denial be reviewed. A licensed health care professional chosen by the Hospital will review your request and denial, and we will comply with the outcome of the review. If you request copies the Hospital will charge you a fee. For more information about this right, see 45 C.F.R. 164.524.

Right to Amend - If you feel that health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing and must provide a reason to support the amendment. We ask that you use the form (Request for Amendment to Protected Health Information) provided by our facility to make such a request. For a request form, please contact the Hospital's Privacy Officer. We may deny your request for an amendment, if it is not in writing or does not include a reason to support the request, if you ask to amend information that:

  • Was not created by the Hospital health care team, unless the person or entity that created the information is no longer available to make the amendment.
  • Is not part of the health information kept by or for the Hospital.
  • Is not part of the information which you would be permitted to inspect and copy.
  • Is accurate and complete.

For more information about this right, see 45 C.F.R. 164.526

Right to Accounting of Disclosures - This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made with your authorization . The right to receive this information is subject to certain exceptions, restrictions and limitations. For more information about this right see 45 C.F.R. 164.528.

Right to Request Confidential Communications
- You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications you must make your request in writing to the Hospital's Privacy Officer. We will accommodate all reasonable requests and your request must specify where you want to be contacted. For more information about this right see 45 C.F.R. 164.522(b).

Right to a Paper Copy of This Notice - You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. You will be asked to sign a receipt that you have received a paper copy.

Right to Revoke an Authorization - You have the right to revoke an authorization made to use or disclose health information, except to the extent that action has already been taken. Such a request must be made in writing to the HCH Medical Records Department.

VI. Changes to This Notice

The Hospital reserves the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change we will place a notice in the local paper stating that our practice has changed and post the updated notice on the Hospital website. The Hospital will provide you with a copy of the current notice and you will be asked to sign a receipt that you have received the notice. The notice will contain the effective date on the top right hand corner of the first page. In addition, each time you register or are admitted to the Hospital for treatment or health care services we will offer you a copy of the current notice in effect.

VII. Complaints

If you believe your privacy rights have been violated you may file a complaint with the Hospital. These complaints must be filed in writing to:

Holy Cross Hospital
Risk Management Department - HIPAA
PO Box DD
Taos, New Mexico 87571

You may also file a complaint with the Secretary of the Federal Department of Health and Human Services. There will be no penalty or retaliation for filing a complaint.

VII. For More Information

If you have any questions and would like additional information, you may contact our Hospital's Privacy Officer at (575) 758-8883 ext. 5739.

Notice of Information and Privacy Practices
Patient’s Rights and Responsibilities

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