NOTICE OF PRIVACY PRACTICES

Effective Date:  APRIL 2, 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 THIS NOTICE CAREFULLY

If you have any questions about this notice, please contact the

Privacy Officer
1115 Lane 12
Lovell, WY  82431
(307) 548-5222

WHO WILL FOLLOW THIS NOTICE

This notice describes our organization’s practices and that of:

• Any healthcare professional authorized to enter information into your medical record at North Big Horn Hospital district, including physicians, dentists, podiatrists and other independent health   care providers.  They have agreed to abide by the terms of the current North Big Horn Hospital District Notice of Privacy Practices for services provided at North Big Horn Hospital and Clinic at any location and to share information as necessary to carry out treatment, payment or health care operations related to North Big Horn Hospital District.
• All departments and units of  North Big Horn Hospital district.
• Any member of a volunteer group we allow to help you while you are in the organization.
• All employees, staff, students, volunteers and other North Big Horn Hospital District personnel.
• This notice applies to all protected health care information maintained by NBHH at any location.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal.  We, at NBHH are committed to protecting the confidentiality of medical information about you.  We create a record of the care and services you receive in our organization.  We need this record 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 anywhere in our organization, whether made by hospital, care center, clinic personnel or your personal doctor.  Your personal doctor may have different policies or notices regarding his/her use and disclosure of your medication information created in the doctor’s office or clinic if your personal doctor does not practice in the North Big Horn Hospital District clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you.
We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
 

We are required by law to:

• Maintain the privacy of your protected health information;
• Give you notice of our legal duties and privacy practices with respect to protected health information and;
• Abide by the terms of the NBHH‘s privacy notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information.  For each category of uses or disclosures, we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment.    We may use medical information about you to provide, coordinate, or manage your health care and related services.  We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you.  For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.  In addition, the doctor may need to tell the dietician if you have diabetes so that we can arrange for appropriate meals.  Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, labwork and x-rays.  We also may disclose medical information about you to people outside our organization, such as family members, clergy or others we use to provide services that are part of your care. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from our care.
• For Payment.  We may use and disclose medical information about you related to obtaining payment for the provision of healthcare.  For example, we may need to give your heath plan or a third party payor information about surgery you received at the hospital so your health plan or payor will pay us or reimburse you for the surgery.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.  We may also disclose information to another health care provider or entity eligible to receive such information for its own payment activities.  For instance, if you are brought to a hospital by an ambulance, we may share information with the ambulance company to allow it to bill you or your insurer.
• For Healthcare Operations.  We may use and disclose medical information about you for our organization operations.   As an organization committed to providing high quality and efficient care, we use information to conduct quality assessment and improvement activities, to review the competence or qualifications of health care professionals and to conduct training and education programs so health care providers improve their skills and all personnel comply with applicable professional, licensure, safety, and accreditation standards.  We may also use and disclose information to conduct or arrange for legal services or for auditing and monitoring, including fraud and abuse detection and compliance programs.  Business planning and development, management and general administrative activities, grievance resolution, customer service activities, and grievance and complaint resolution are all routine operational activities that may require use and disclosure of certain protected information.  We may also use and disclose medical information as part of any reorganization of operations, including one that results in a new or reorganized entity that is subject to privacy protections.  Often we track information over time on patient care issues or combine medical information about many patients in order to engage in these operational activities.
• Appointment Reminders.  We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at North Big Horn Hospital District.
• Treatment Alternatives.  We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
• Health-Related Benefits and Services.  We may use and disclose medical information to contact you about health-related products or services we provide, including communications about health care provider networks, plans and benefits.
• Fundraising Activities.  We may use certain information about you to contact you in an effort to raise money for North Big Horn Hospital District and its operations.  We may disclose medical information to a foundation related to North Big Horn Hospital District so that the foundation may contact you in raising money for our organization.  We would release only contact information, such as your name, address and phone number, and the dates you received treatment or services at North Big Horn Hospital, Clinic or New Horizons Care Center.
  If you do not want the North Big Horn Hospital District or NBHH Foundation to contact you for fundraising efforts, you may “opt out” of future fundraising efforts by notifying NBHH Foundation or NBHH’s privacy Officer in writing.  We then will make good faith efforts not to contact you after we have received and processed your opt-out request.
• Hospital Directory.  Unless you request that such information not be released, we may include certain limited information about you in the hospital or nursing home directory while you are a patient in the hospital or nursing home.  This information may include your name, location in the hospital or nursing home, your general condition (e.g., fair, stable, etc.), and your religious affiliation.  The directory information, except for your religious affiliations, may also be released to people who ask for you by name.  Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name.  This is so your family, friends and clergy can visit you in the hospital or nursing home, and generally know how you are doing.
• Individuals Involved in Your Care or Payment for Your Care.  Unless you object, we disclose to a family member, other relative, or a close personal friend, or any other person you identify, protected health information directly relevant to that person’s involvement with your care or payment related to your care.  We will also disclose protected health information to an individual if we reasonably infer from the circumstances, based on the exercise of professional judgment that you do not object to the disclosure.
• Research.  Under certain circumstances, we may use and disclose medical information about you for research purposes.  For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information.  Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may however, disclose medical information about you to people preparing to conduct a research project.  For example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the organization.  We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care anywhere at North Big Horn Hospital District, unless we have received approval from an Institutional Review Board waiving authorization requirements.
• As Required By Law.  We will disclose medical information about you when required to do so by federal, state or local law.
• To avert a Serious Threat to Health or Safety.   We may use and disclose medical information about you when necessary to prevent or lesson a serious threat to your health and safety or the health and safety of the public or another person, unless that information is learned during counseling, therapy or treatment to affect the propensity to engage in such criminal conduct. .  Any disclosure, however, would only be to someone able to help prevent the threat.
• In the Event of a Disaster.  We may disclose medical information about you to other health care providers and to an entity assisting in a disaster relief effort to coordinate care and so your family can be notified about your condition and location.
• Business Associates.  We may disclose medical information to business associates with whom we contract so they may provide services on behalf of NBHH.  We require all business associates to implement safeguards to protect medical information.
• Cancer Registry and other Registries.  If you have been diagnosed with cancer, we may release medical information about you to authorized cancer registries. We may also be required by law to release information to other registries.  This information is aggregated with other information and is used to monitor current treatment practices and develop new protocols to treat cancer and other medical conditions.

SPECIAL SITUATIONS

• Organ and Tissue Donation.   If you are an organ donor, we may releasemedical information to organizations that handle 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 medical information about you as required by military command authorities.  We may also release medical information about foreign military personnel of the appropriate foreign military authority.
• Workers’ Compensation.   We may release medical information about you for Workers’ Compensation or similar programs.  These programs provide benefits for work-related injuries or illness.
• Public Health Risks.   We may disclose medical information about you for public health activities.  These activities generally include the following:
• To a public health authority authorized by law to collect information for the purpose of  preventing or controlling disease, injury or disability; including, but not limited to, the reporting of disease, injury, vital events such as births and deaths, conducting public health surveillance, investigations and interventions, or, at the direction of a public health authority, disclosing information to an official of a foreign government agency that is collaborating with a public health authority;
• To a public health authority or other appropriate government agency authorized to receive reports of actual or suspected child abuse or neglect;
• To a person responsible for federal Food and Drug Administration activities for purposes related to the quality, safety or effectiveness of FDA-regulated products or activities;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition, as authorized by law;
• To an employer, when required by federal or state law, to conduct medical surveillance of the workplace or to evaluate whether an individual has a work-related illness or injury.
   
• Victims of Abuse, Neglect or Domestic Violence   We may disclose protected health information about an individual we reasonably believe to be the victim of abuse, neglect or domestic violence to a person authorized by law to receive such reports.  We will make this disclosure with the individual’s agreement, or if the disclosure is required or authorized by law and we believe the disclosure is necessary to prevent harm to an individual or other potential victims.  Also if the patient is incapacitated, we may disclose information to a person authorized to receive such reports, if that person represents that the protected health information is not intended to be used against the patient or individual and that an immediate enforcement activity depends upon the disclosure.
• Health Oversight Activities.  We may disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities include – for example, audits, investigations, inspections and licensure or disciplinary activities; legal proceedings or actions; or other activities necessary for appropriate oversight of the health care system, government benefit programs, and compliance with government regulatory programs or civil rights laws for which health information is necessary for determining compliance.
• Lawsuits and Disputes.   If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order.    We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or obtain an order protecting the information requested.
• Law Enforcement.   We may release medical information if asked to do so by a law enforcement official:
• as required by law that mandates reporting of certain types of wounds or injuries;
• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness or missing person;
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• about the victim of a crime if we obtain the individual’s agreement or we receive certain representations from a law enforcement official and the disclosure is in the individual’s best interest, in the exercise of   professional judgment;
• about criminal conduct at NBHH; and
• in emergency circumstances to report a crime; the location of a crime or victims; or the identity, description or location of the person who committed the crime.
• Coroners, Medical Examiners and Funeral Directors.    We may release medical information to a coroner or medical examiner.  This may be necessary, for example to identify a deceased person or determine the cause of death.  We may also release medical information about patients of the hospital or nursing home to funeral directors as necessary to carry out their duties.
• National Security and Intelligence Activities.  We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• Protective Services for the President and Others.  We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations authorized by law.
• Inmates.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the authorities of a correctional institution or law enforcement official.  This release would be necessary (1) for the institution to provide you with healthcare; (2) to protect your health and safety or the healthy and safety of others; or (3) for the safety and security of the correctional institution.
• Specially Protected Health Information.  Unless otherwise required or permitted under law, use and disclosure of the following information is subject to additional privacy protections:  AIDS/HIV/ARC information, mental health and mental illness records, drug addiction, alcoholism, and other substance abuse treatment records, developmental disability records, and genetic information.
• Incidental Disclosures.  Certain incidental disclosures of our medical information may occur as a by-product of permitted uses and disclosures.  For example, a visitor may inadvertently overhear about your care occurring at the nurse’s station.
• Limited Data Sets.  We may disclose limited medical information to third parties for research, public health, and health care operations.  Before disclosing such information, we will enter into an agreement that limits the recipient’s use and disclosure of the information and prohibits the recipient from attempting to re-identify the data or contact you.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of your health information will be made only with your written permission.  If you provide NBHH with an authorization, you may revoke it, in writing, at any time (unless you are informed otherwise at the time you sign the authorization).  If you revoke permission, we will no longer use or disclose your health information for the reasons covered by the authorization.  We are unable to take back any disclosures already made with your permission and are required to retain records of the care we provide to you.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy.  You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to North Big Horn Hospital District Health Information Management Department.  If you request a copy of the information, we may charge you for the costs of the copying, mailing or other supplies associated with your request.

  We may deny your request to inspect and copy in certain, very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed healthcare professional chosen by NBHH will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.  In certain limited situations, we will have to deny your request for access but will not be able to give you a review.

• Right to Amend.   If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for North Big Horn Hospital District in any of its locations.

To request an amendment, your request must be made in writing and submitted to North Big Horn Hospital District Health Information Management Director.  In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that:

•  was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the medical information kept by or for North Big Horn Hospital District.
• is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.

If you disagree with our denial, you may submit a statement of disagreement or ask that your request become part of your record.  In response, we may prepare a rebuttal as part of your record.

• Right to an Accounting of Disclosures.  You have the right to request an “accounting of disclosures”.  This is a list of the disclosures we made about your medical information.  This accounting will not include disclosures for treatment, payment, or health care operation; for facility directory purposes, to persons involved in your care, or for notification purposes; incidental to an otherwise permitted use or disclosure; to correctional institutions or other custodial law enforcement official; as part of a limited data set; for national security or intelligence purposes; or that you authorized or requested.

To request this list or accounting of disclosures, you must submit your request in writing to North Big Horn Hospital District Privacy Officer.  Your request must state a time period that may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, on paper, electronically).  The first list you request with a 12-month period will be free.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

• Right to Request Restrictions.  You have a right to request a restriction or limitation on our use or disclosure of our protected health information.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

• To request restrictions, you must make your request in writing to North Big Horn Hospital District Privacy Officer.  In your request you must tell us (1) what information you want to limit;  (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
• 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 North Big Horn Hospital District Privacy Officer.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.
• 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.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our website, www.nbhh.com.
 

To obtain a paper copy of this notice, you may receive one at any registration desk or by submitting your request in writing to:

PRIVACY OFFICER
North Big Horn Hospital
1115 Lane 12
Lovell, WY  82431

CHANGES TO THIS NOTICE

NBHH reserves the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.  We will post a copy of the current notice in each facility within our organization as well as on our web-site, www.nbhh.com.  The notice will contain on the first page, in the top right-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the North Big Horn Hospital District, or with the Secretary of the Department of Health and Human Services.  To file a complaint with North Big Horn Hospital District, contact:

PRIVACY OFFICER
North Big Horn Hospital
1115 Lane 12
Lovell, WY  82431

All complaints must be submitted in writing.  You will not be penalized for filing a complaint.
 

NORTH BIG HORN HOSPITAL DISTRICT

Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Health Information for Treatment, payment, or Healthcare Operations

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.  I understand that this information serves as:

• A basis for planning my care and treatment
• A means of communication among the many health professionals who contribute to my care
• A source of information for applying my diagnosis and surgical information to my bill
• A means by which a third-party payer can verify that services billed were actually provided
• And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures.  I understand that I have the right to review the notice prior to signing this consent.  I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided.  I understand that I have the right to object to the use of my health information for directory purposes.  I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested.  I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.