Conway Medical Center :: Patients & Visitors > Notice of Privacy Practices

PURPOSE:
To ensure that Conway Medical Center and its affiliates understand the requirement to provide a Notice of Privacy Practices to all patients as required by the Health Insurance Portability and Accountability Act (HIPAA), Standards of Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164, and any and all other Federal regulations and interpretive guidelines.

POLICY STATEMENT:
Conway Medical Center and its affiliates must provide adequate Notice of Privacy Practices to patients. The facility must also inform patients of their rights with respect to protected health information (PHI) as well as the facility’s legal duties. The patient must acknowledge receipt of the notice.

DEFINITIONS:
Affiliated Covered Entity - Entities under common ownership or control may designate themselves as Affiliated Covered Entity.

Direct treatment relationship - A relationship between a healthcare provider and patient where the healthcare provider delivers healthcare directly to the individual.

Organized Health Care Arrangement - A clinically integrated care setting in which individuals typically receive healthcare from more than one healthcare provider. The facility and its medical staff are an Organized Health Care Arrangement under the rule.

PROCEDURES:
1. Conway Medical Center must provide a notice that is written in plain language and that includes, at a minimum, Conway Medical Centers standard notice language attached to this policy. There may be facility situations that warrant additions to the standard form such as research programs. These additions may be made at the discretion of the Hospital Privacy Officer (HPO) in consultation with the facility committee responsible for the Privacy Program and, in appropriate circumstances with the facility’s Legal Counsel.

2. The patient must acknowledge in writing (i.e. initial) receipt of the Notice of Privacy Practices. This acknowledgement has been included in the Conditions of Treatment form, which is completed at the time of the patient’s registration.

3. Required Elements:
a. The header statement must state: “This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.”
b. A description, including at least one example, of the types of disclosures for the purpose of treatment, payment and healthcare operations
c. A description of each of the other purposes for which the facility is permitted or required to use or disclose the information without an individual’s consent or authorization.
d. A statement that is a use or disclosure is prohibited or materially limited by other applicable law; the description of such use or disclosure must reflect the more stringent law.
e. A statement that the facility may contact the individual to: a) provide appointment reminders; b) provide information about treatment alternatives; c) provide information about other health-related benefits and services; or d) conduct fundraising efforts, as applicable and one or more of these communications may be left on the patient’s answering machine/voice mail.
f. A statement that other uses or disclosures will be made only with the individual’s written authorization and that the individual may revoke this authorization.
g. A statement of the patient’s rights with respect to protected health information (PHI)
· The right to access protected health information policy (XXXXX)
· The right to amend protected health information policy (XXXX)
· The right to receive confidential communications (XXXX)
· The right to an accounting of disclosures (XXXXX)
· The right to request restrictions on certain uses and disclosures (XXXXX)
· The right to obtain a copy of the notice.
h. A statement of Conway Medical Center duties with respect to protected health information (PHI)
· Conway Medical Center is required by law to maintain the privacy of PHI and to provide this notice with respect to PHI
· Conway Medical Center must abide by the terms of the notice;
· Conway Medical Center may apply a change to the notice and make the new notice effective for all the PHI it maintains. The statement will also include how it will provide the revised notice to individuals.
i. A statement that patients may complain to the Hospital Privacy Officer or the Secretary of the U.S. Department of Health and Human Services if they believe their privacy rights have been violated, a brief description of how the individual may file a complain, and a statement that the individual will not be retaliated against for filing the complaint.
j. A statement that includes the name or title and telephone number of the Hospital Privacy Officer.
k. The effective date of the notice
l. A statement that the notice may change.

4. Conway Medical Center and its affiliates that have a direct treatment relationship with patients must:
· Provide the notice no later that the date of the first treatment service delivery subsequent to the effective date of the Privacy Standards, April 14, 2003.
· Have the notice posted in a clear and prominent location where it is reasonable to expect individuals seeking service from the facility to read the notice; and
· Have the notice available for individuals to take with them.

5. The website for Conway Medical Center must prominently post its notice on the website and make the notice available electronically through the website.

6. Conway Medical Center may provide the notice by e-mail. A paper copy must be provided at the request of the patient or if the mail transmission fails.

7. If the first treatment service delivery to a patient is delivered electronically, Conway Medical Center must provide the notice automatically and immediately. The individual may obtain a paper copy at his or her request.

8. For recurring patients the notice may be provided at the initial interaction and does not need to be provided again unless a change has been made.

9. Conway Medical Center will document compliance by retaining copies of the notices issued in the patient’s medical record.

10. Conway Medical Center may review and update the privacy notice but must distribute its notice whenever there is a material change to the uses or disclosures, individuals rights, legal duties or other privacy practices stated in the notice. A material change to any terms of the notice may not be implemented prior to the effective date of notice in which a material change is reflected.