FRIENDSHIP
HAVEN
NOTICE OF
PRIVACY PRACTICES
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.
DEFINITIONS
"Protected health
information" means any individually identifiable health information that
relates to your past, present, or future physical or mental health or
condition; the provision of health care to you; or the past, present, or future
payment of health care provided to you.
Protected health information includes demographic information, such as
your name and address, which can be used to identify you.
"We" or
"us" or "our" means Friendship Haven.
"You" or
"your" means an individual who receives or has received health care
services from Friendship Haven. If a
person has legal authority to act on your behalf in making decisions related to
your health care, "you" or "your" will pertain to your
personal representative to the extent relevant and appropriate to their
representation.
PURPOSE
The purpose of this Notice
of Privacy Practices is to explain your rights and our legal duties concerning
the use and disclosure of your protected health information by Friendship
Haven.
We reserve the right to
change this notice and make the new notice effective for all protected health
information maintained by us, including the protected health information
created or received by us prior to the effective date of the new notice. We will post a copy of the new notice in a
clear and prominent location in the facility, and will provide a copy of it to
you upon request.
OUR LEGAL DUTIES
Friendship Haven is required
by law to maintain the privacy of your protected health information and to
provide you with a notice of its legal duties and privacy practices. An explanation of our legal duties and
privacy practices regarding your protected health information is provided
below. We may not use or disclose your
protected health information in a manner that is inconsistent with our current
Notice of Privacy Practices.
We may share your protected
health information with third party "business associates" that
perform various activities (e.g., billing, consulting, or administrative
services) on our behalf. Whenever an
arrangement between Friendship Haven and a business associate involves the use
or disclosure of your protected health information, we will have a written
contract that contains terms that will protect the privacy of your protected
health information.
Uses and Disclosures of
Protected Health Information Requiring Your Written Authorization
Uses and disclosures of your
protected health information will be made only with your written authorization,
unless otherwise permitted or required by law as described in this Notice of
Privacy Practices. You may revoke an
authorization, at any time, in writing, except to the extent we have already
taken an action in reliance on the use or disclosure indicated in the
authorization.
Permitted Uses and
Disclosures of Your Protected Health Information for Treatment, Payment and
Health Care Operations
The following sections
describe different ways that we can use and disclose your protected health
information for treatment, payment, and health care operations. For each of these categories, we have
included an example to explain what we mean.
Treatment Purposes
We may use your protected
health information, without your authorization, necessary to provide you
treatment and services. We may also
disclose your protected health information to other health care providers
involved in your medical treatment. An
example of a permitted use of your protected health information for treatment
purposes is our use of the information to provide you appropriate care and
treatment. An example of a permitted
disclosure of your protected health information for treatment purposes is our
disclosure of the information to your physician or to a hospital to ensure they
have the necessary information to diagnose or treat you.
Payment Purposes
We may use and disclose your
protected health information, without your written authorization, to bill for
the treatment and services provided to you, and to obtain payment for those services
from you, a health plan, or a third party.
An example of a permitted use of your protected health information for
payment purposes is our use of the information to bill you or your personal
representative for the health care services you receive from Friendship
Haven. An example of a permitted
disclosure of your protected health information for payment purposes is our
disclosure of the information to a health plan as a part of a claim for payment
for the services provided to you.
Health Care Operations
We may use or disclose your
protected health information, without your written authorization, in order to
conduct certain activities that are necessary to operate our business and
manage our quality of care. An example
of a permitted use of your protected health information for health care
operations is our use of the information to review our treatment and services
and to evaluate and improve the performance of our health care staff. An example of a permitted disclosure of your
protected health information for health care operations is our disclosure of
the information to student trainees for educational purposes.
Incidental Uses or
Disclosures
There may be other
incidental uses or disclosures of your protected health information that may be
permitted, but are not specifically listed as examples in our Notice of Privacy
Practices. We will make reasonable
efforts within our means to limit our use and disclosure of your protected
health information to the minimum necessary, and to employ reasonable
safeguards to protect the privacy of your protected health information.
Other Permitted and Required
Uses and Disclosures of Your Protected Health Information
Facility Directory
Unless you express an
objection, we may use certain limited information about you to maintain a
facility directory. This information may
include your name, your location in the facility, a general description of your
condition (e.g., recently released from the hospital), and your religious
affiliation. Our directory does not
include specific medical information about you.
We may release information in our directory, except for your religious
affiliation, to people who ask for you by name.
We may provide the directory information, including your religious
affiliation, to any member of the clergy.
You have the right to
prohibit or restrict the use or disclosure of some or all of your protected
health information for the facility directory.
If you are not able to agree or object to the use or disclosure of information
in our directory, we may use or disclose the information, provided that our use
or disclosure of the information is consistent with your prior expressed
preference or, in our professional judgment, we believe it is in your best
interest to use or disclose the information.
Disclosures to Individuals Involved in Your Health Care or in the
Payment of Your Health Care
Unless you express an
objection, we may disclose to a member of your family, another relative, a
close personal friend, or any other person you identify, your protected health
information that relates directly to the person's involvement with your health
care or payment of your health care. If
you are unable to agree or object to such a disclosure, we may disclose your
protected health information, as necessary, to these individuals, if we
determine in our professional judgment that it is in your best interest to
disclose the information.
Uses or Disclosures for Notification Purposes
Unless you express an
objection, we may use or disclose your protected health information to notify
or assist in notifying a member of your family, your personal representative,
or any other person that is responsible for your care, of your location,
general condition, or death. If you are
unable to agree or object to such a disclosure, we may disclose such
information for notification purposes if we determine in our professional
judgment that it is in your best interest to disclose the information.
Uses or Disclosures to Disaster Relief Organizations
We may use or disclose your
protected health information to a disaster relief organization to assist the
organization in notifying a member of your family, your personal
representative, or another person responsible for your care, of your location,
general condition, or death. If you are
unable to agree or object to such a disclosure, we may disclose such
information for notification purposes if we determine in our professional
judgment that it is in your best interest to disclose the information.
Before we disclose your protected
health information to a disaster relief organization, we will first obtain your
agreement or provide you with an opportunity to object to the disclosure,
unless we determine, in our professional judgment, that obtaining your
agreement or objection will interfere with the ability of the disaster relief
organization to respond to emergency circumstances.
Uses and Disclosures Required by Law
We may use or disclose your
protected health information to the extent required by law. Such use or disclosure will be made in
compliance with the law and will be limited to the relevant requirements of the
law. When required by law, we may use or
disclose your protected health information without your authorization or without
providing you with an opportunity to agree or object to such use or
disclosure. We will notify you, as
required by law, of any such uses or disclosures.
Disclosures to You
We are required by law to
disclose your protected health information to you, when you request it, subject
to our right to deny you access to the information when permitted or required
by law.
Disclosures to Personal Representatives
If you are an unemancipated
minor, there may be circumstances when we will disclose your protected health
information to a parent, guardian, or other person acting in loco parentis, in accordance with our legal and ethical
responsibilities. If you are an adult or
emancipated minor, we may disclosure you protected health information to a
personal representative authorized to act on your behalf in making decisions
about your health care.
Disclosures to the U.S. Department of Health and Human Services
We are required by law to
disclose your protected health information to the U.S. Department of Health and
Human Services during an investigation of our compliance with federal laws
protecting the privacy of your protected health information. Such disclosure may be made without your
authorization or without providing you with an opportunity to agree or object.
Reporting Dependent Adult Abuse
We are required by law to
disclose your protected health information to the Iowa Department of
Inspections and Appeals or the Iowa Department of Human Services, if we believe
you are a victim of dependent adult abuse.
Such disclosure may be made without your authorization or without
providing you with an opportunity to agree or object.
Disclosures in a Judicial or Administrative Proceeding
We may disclose your
protected health information in response to, and to the extent required by, a
court or administrative order. We may
also disclose your protected health information in response to a subpoena,
discovery request, or other lawful process, provided that we receive
satisfactory assurance from the party seeking the information that reasonable
efforts have been made to notify you of the request or to obtain an order or
agreement protecting the information.
Such disclosures may be made without your authorization or without
providing you with an opportunity to agree or object.
Disclosures for Law Enforcement Purposes
We may disclose your
protected health information for a law enforcement purpose to a law enforcement
official in any of the following circumstances:
(1) As required by law, including laws that require the reporting
of certain wounds or other physical injuries which appear to have been received
in connection with the commission of a criminal offense;
(2) In compliance with a court order, subpoena, or administrative
request seeking information that is relevant and material to a law enforcement
inquiry;
(3) To identify or locate a suspect, fugitive, material witness,
or missing person, provided such disclosure is limited to the information
permitted by law;
(4) In response to a law enforcement official's request about a
known or suspected victim of a crime, when you agree to the disclosure;
(5) To report information about a suspicious death resulting from
criminal conduct;
(6) To provide information about criminal conduct occurring on
our premises; or
(7) When necessary to identify or apprehend an individual who
participated in a violent crime or escaped from lawful custody, provided such
disclosure is limited to the
information permitted by law.
Such disclosures may be made
without your authorization or without providing you with an opportunity to
agree or object.
Disclosures for Public Health Activities
We may disclose your
protected health information for the following public health activities and
purposes:
(1) To a public health authority authorized by law to receive
information for the purpose of preventing or controlling disease, injury, or
disability;
(2) To a representative of the federal Food and Drug
Administration (FDA) for authorized activities related to the quality, safety,
or effectiveness of FDA-regulated products or activities; or
(3) To an employer, about a member of the employer's workforce,
if Friendship Haven has provided health care to the member at the employer's
request, concerning a work-related illness or injury or a workplace-related
medical surveillance, in order for the employer to comply with its legal
obligations.
Such disclosures may be made
without your authorization or without providing you with an opportunity to
agree or object.
Disclosures for Health Oversight Activities
We may disclose your
protected health information to a health oversight agency for oversight
activities authorized by law, such as audits, inspections, or investigations,
conducted for the purpose of overseeing the health care system, government
health benefit programs, other government regulatory programs for which health
information is necessary to determine compliance with program standards, or
entities subject to civil rights laws for which health information is necessary
for determining compliance with the laws.
Such disclosures may be made without your authorization or without
providing you with an opportunity to agree or object.
Disclosures to Coroners and Funeral Directors and Organ Procurement
Organizations
We may disclose your
protected health information to a coroner or medical examiner for
identification purposes, to determine cause of death, or to carry out other
duties authorized by law. We may also
disclose your protected health information to funeral directors or persons
responsible for transporting deceased individuals, in accordance with law, as
necessary to carry out their duties. A
disclosure to a funeral director may be made prior to, and in reasonable
anticipation of, death. If you are a
donor, your protected health information may be used or disclosed for organ,
eye, or tissue donation purposes. Such
disclosures may be made without your authorization or without providing you
with an opportunity to agree or object.
Disclosures for Research Purposes
We may use or disclose your
protected health information for authorized research purposes, provided that
the researcher adheres to certain privacy practices, including obtaining
approvals from an authorized Privacy Board or an Institutional Review
Board. Your protected health information
may be used for board approved research purposes only if the researcher is
collecting information in preparing a research protocol or the research occurs
after your death. Such disclosures may
be made without your authorization or without providing you with an opportunity
to agree or object.
Participation in
experimental research requires your written informed consent, which consent may
be combined in a written authorization to use or disclose your protected health
information for the experimental research study.
Uses and Disclosures to Avert a Serious Threat to Health or Safety
We may use or disclose your
protected health information if we believe 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, and the disclosure is made to persons reasonably able to
prevent or lessen the threat. Such uses
and disclosures may be made without your authorization or without providing you
with an opportunity to agree or object.
Uses and Disclosures for Specialized Government Functions
(1) Military Activities. If you are a member of the armed forces, we
may use and disclose your protected health information as required by military
command authorities. We may also use and
disclose protected health information about foreign military personnel as
required by the appropriate foreign military authority.
(2) National Security and
Intelligence Activities. We may
disclose your protected health information to authorized federal officials
conducting lawful intelligence, counter-intelligence, and other national
security activities authorized by law.
(3) Protective Services for
the President and Others. We may
disclose protected health information to authorized federal officials providing
protective services to authorized persons, including the President or foreign
heads of state, or in connection with conducting authorized investigations.
(4) Correctional Institutions
and Other Law Enforcement Custodial Situations. We may disclose to a correctional institution
or a law enforcement official with lawful custody of an inmate necessary
protected health information about the individual, provided that the individual
has not been released on parole, probation, supervised release, or otherwise is
no longer in lawful custody.
Such uses and disclosures
may be made without your authorization or without providing you with an
opportunity to agree or object.
Disclosures for Worker's Compensation
We may disclose your
protected health information as authorized to comply with laws relating to
worker's compensation or other similar legally established programs that
provide benefits for work-related injuries or illness. Such uses and disclosures may be made without
your authorization or without providing you with an opportunity to agree or
object.
Uses and Disclosures for Appointment Reminders
We may use or disclose your
protected health information to remind you about appointments.
Uses and Disclosures to Provide Information about Treatment
Alternatives or Other Health-Related Benefits and Services
We may use or disclose your
protected health information to provide you with information about treatment
alternatives or other health-related benefits and services that may be of
interest to you.
Uses and Disclosures for Fundraising Activities
We may use certain protected
health information, limited to your contact information, such as your name,
address, and telephone number and the dates you received treatment or services
from us, for the purpose of contacting you to raise money for the
facility. We may also disclose the same
limited information to a business associate or a foundation related to
Friendship Haven for the purpose of contacting you to raise money on our behalf.
More Stringent Laws
In some circumstances, your
protected health information may be subject to other laws and regulations that
afford greater protections than what is outlined in this Notice of Privacy
Practices. For example, disclosure of
information pertaining to HIV/AIDS related testing, substance abuse, and mental
health information may be subject to more stringent standards than described
here. In the event your protected health
information is afforded greater protection under federal or state law, we will
comply with the requirements of those laws.
YOUR RIGHTS
You have certain legal
rights regarding your protected health information maintained by or for
Friendship Haven.
Right of Access
You have the right to
inspect and obtain a copy of your protected health information contained in a
designated record set for as long as we maintain the information. A "designated record set" contains
your clinical records, personal records, and financial records and other
records used by us to make decisions about your health care. Any requests to inspect and obtain a copy of
your protected health information may be made orally or in writing to our
Privacy Official. We may charge a
reasonable fee for our costs in copying and mailing your requested information.
We may deny your request to
inspect or receive copies in certain limited circumstances. If we deny you access, you have the right,
under some circumstances, to have the denial reviewed by a licensed health care
professional who did not participate in the original decision to deny. We will provide or deny access in accordance
with the determination of the reviewing official, and promptly provide you with
written notice of the reviewing official's determination.
Right to Amend Your
Protected Health Information
You have the right to
request that we amend your protected health information contained in a
designated record set for as long as we maintain this information. Your request
for an amendment to your protected health information must be submitted in
writing to our Privacy Official and must provide a reason for the request. If we grant your request for an amendment,
we will make the appropriate amendment to your protected health information in
the designated record set and will notify appropriate parties of the amendment.
We may deny your request for
amendment under certain circumstances permitted by law. If we deny your request
for an amendment, we will provide you with a timely, written denial explaining
the basis for our denial. If we deny
your request for an amendment, you have the right to file a statement of
disagreement with us. We may prepare a
rebuttal to your statement of disagreement and, if we do so, will provide you
with a copy of our rebuttal.
Right to Request a
Restriction of Your Protected Health Information
You have the right to
request restrictions on our use or disclosure of your protected health
information for treatment, payment, or health care operations. You also have the right to restrict the
protected health information that we disclose to a member of your family,
another relative, a close personal friend, or any other person identified by
you, who is involved in your health care or payment of your health care, or for
notification purposes, as described in this Notice of Privacy Practices.
We are not required to agree
to a restriction requested by you, except that while you are capable of making
health care decisions, you may restrict disclosures to family members,
relatives, or friends. If we agree to a
requested restriction, we will comply with your request, except when the use or
disclosure of your protected health information is needed to provide you with
emergency treatment. We may terminate
our agreement to a restriction when you agree or request the termination, or
when we inform you that we are terminating the restriction. We will not agree to a restriction that
restricts uses or disclosures required by law.
Right to Receive
Confidential Communications
You have the right to
request to receive confidential communications from us by alternative means or
at an alternative location. We will
accommodate reasonable requests made to us in writing to our Privacy
Official. We may condition our
accommodation of your request upon receiving information from you, when
appropriate, about how payment for treatment and services will be handled and
specifying an alternative address or other method of contact. We will not require an explanation from you
of the reasons for your request as a condition of providing communications to
you on a confidential basis.
Right to Receive an
Accounting of Disclosures
You have the right to
receive an accounting of disclosures of your protected health information made
by us to others in the six years prior to your request (or such shorter time
period as requested by you). This right
applies to disclosures for purposes other than treatment, payment, or health
care operations and excludes, among others, disclosures made to you,
disclosures made to your family members or friends involved in your care,
disclosures of information contained in the facility directory, disclosures
made for notification purposes, disclosures made pursuant to an authorization,
and disclosures made prior to April 14, 2003.
Your right to receive an accounting of disclosures is subject to certain
exceptions, restrictions, and limitations.
To request an accounting of
disclosures, you must submit a request in writing to our Privacy Official,
stating a time period beginning after April 13, 2003 that is within six years
from the date of your request. An
accounting will generally include the following information: (1) the date of the disclosure; (2) the name
and, if known, the address of the entity or person who received your protected
health information; (3) a brief description of the protected health information
disclosed; and (4) a brief statement of the purpose of the disclosure or a copy
of the written request. In lieu of the
information listed above, we may provide you with a summary instead, if the
disclosures involved multiple similar disclosures. The first accounting provided to you within a
12-month period will be provided for free.
We reserve the right to charge a reasonable, cost-based fee for each
subsequent request made within the same 12-month period.
Right to Receive a Paper
Copy of this Notice
You have a right to receive
a paper copy of our Notice of Privacy Practices, even if you have agreed to
receive the notice electronically. You
may request a copy of our Notice of Privacy Practices at any time. You may also obtain a copy of our Notice of
Privacy Practices at our web site at www.friendshiphaven.org.
COMPLAINTS
If you believe that we have
violated your privacy rights, you may file a complaint in writing with us or
with the U.S. Department of Health and Human Services Office of Civil
Rights. You may file a complaint with us
by notifying our Privacy Official of your complaint. We will not retaliate against you for filing
a complaint.
CONTACT
INFORMATION
The responsibilities of the
Privacy Official are carried out by the Social Services Director. You may contact the Privacy Official if you
have questions about your privacy rights, or to file a complaint about a
violation of your privacy rights, by contacting the Privacy Official at
515-573-6702.
EFFECTIVE DATE
The effective date of this
Notice of Privacy Practices is October 1, 2004.
ACKNOWLEDGMENT
I acknowledge that I have received a copy of Friendship Haven's Notice of Privacy Practices dated October 1, 2004, explaining my rights and its legal obligations regarding the use and disclosure of my protected health information.
______________________________________
Individual or Individual's Legal Representative