Our Privacy Commitment
Effective Date: December 8, 2008
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED,
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
If you have any questions about this notice, please contact:
Director of Health Information Management
The
South Bend
Clinic
211 North Eddy Street
South Bend,
Indiana
46617
This notice describes The South Bend Clinic’s practices and that of:
- Any health
care professional authorized to enter information into your chart.
- All
departments, units, sites and locations of The South Bend Clinic. All
these entities, sites and locations follow the terms of this notice. In
addition, these entities, sites and locations may share medical information with
each other for treatment, payment or clinic operational purposes described in
this notice.
- All
employees, staff, students and other personnel authorized to document in and or
review your chart.
- All
independent contracting staff and providers The South Bend Clinic may determine
is necessary to help you with your care. Those services include, but are
not limited to: anesthesia, laboratory, surgical, and radiological services.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is
personal. We are committed to protecting medical information about you. We
create a record of the care and services you receive at The South Bend Clinic.
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 by The South Bend Clinic, whether made by authorized personnel or your
personal physician.
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:
make sure that
medical information that identifies you is kept private;
give you this
notice of our legal duties and privacy practices with respect to medical
information about you; and
follow the terms
of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL 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 each
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 you with medical
treatment or services. We may disclose medical information about you to doctors,
nurses, technicians, health care students, or other clinic personnel who are
involved in your care and treatment. Different departments of The South Bend
Clinic also may share medical information about you in order to coordinate the
different things you need, such as prescriptions, lab work and x-rays. We also
may disclose medical information about you to people outside The South Bend
Clinic who may be involved in your medical care.
For Billing Purposes:
We may use and disclose medical information about you so that the
treatment and services you receive may be billed to and payment may be collected
from you, an insurance company or a third party. For example, we may need to
give your health plan information about surgery you received at The South Bend
Clinic so your health plan will reimburse you for the related costs. 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 proposed treatment.
For Health Care Operations:
We may use and disclose medical information about you for general business
operations. These uses and disclosures are necessary to operate The South Bend
Clinic and to make sure that all of our patients receive quality care. 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 combine medical information to determine what additional services The South
Bend Clinic should offer, what services are not needed, and whether certain new
treatments are effective.
We may also disclose information to doctors, nurses, technicians, medical
students, and other clinic personnel for review and learning purposes. We may
also combine the medical information we have with medical information from other
physician practices to compare how we are doing and to see where we can make
improvements in the care and services we offer. We may remove information that
identifies you from this set of medical information so others may use it to
study health care and health care delivery without identifying the specific
patient[s].
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 tell you about
health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care:
We may release medical information about you to a friend or family member
that you have requested to be involved in your medical care. We may also give
information to an insurance company or someone who helps pay for your care.
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 a serious threat to your health and safety or the health and safety of
the public or another person. Any disclosure, however, would only be to
someone able to help prevent the threat.
SPECIAL SITUATIONS
Organ and Tissue Donation:
If you are an organ donor, we may release medical 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 to 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 prevent or
control disease, injury or disability;
to report births
and deaths;
to report abuse or
neglect;
to report
reactions to medications or problems with products;
to notify people
of recalls of products they may be using;
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;
to notify the
appropriate government authority if we believe a patient has been the victim of
abuse, neglect or domestic violence. We will only make this disclosure if you
agree or when required or authorized by law.
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. These necessary activities
allow the government to monitor the health care system, government sponsored
programs, and compliance with laws and regulations.
Lawsuits and Disputes:
If you are involved in a lawsuit or a legal 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 to
obtain an order protecting the information requested.
Law Enforcement:
We may release medical information if asked to do so by a law enforcement
official:
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 a death we
believe may be the result of criminal conduct;
About criminal
conduct at the hospital; and
In emergency
circumstances; to report a crime; the location of the 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 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.
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
correctional institution or law enforcement official. This release would be
necessary:
(1) for the institution to provide you
with health care;
(2) to protect your health and safety
or the health and safety of others; or
(3) for the safety and security of the
correctional institution.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding medical information we maintain
about you:
Right to Inspect and Copy:
You have the right to inspect and obtain a copy of your 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.
You have the right to inspect and to obtain a copy of medical information
that may be used to make decisions about you. Please submit your request in
writing to:
(Your Physician) or
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
If you request a copy of medical information, we may charge a fee for the
costs of 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 health care professional chosen by The South Bend
Clinic will review your request and the denial. The person conducting the review
will not be the person who denied your original request. The South Bend Clinic
will comply with the outcome of the 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 The South Bend
Clinic.
To request an amendment, your request must be made in writing and
submitted to:
(Your Physician) or
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
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 The South Bend Clinic;
Is not part of the
information which you would be permitted to inspect and copy; or
Is accurate and
complete.
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 of medical information about you. To request
this list or accounting of disclosures, you must submit your request in writing
to:
(Your Physician) or
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
Your request must state a time period which may not be longer than six
years and may not include dates before April 14, 2003. Your request should
indicate in what form you want the list (for example, on paper, or
electronically). The first list you request within 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 the right to request a restriction or limitation on the medical
information we use or disclose about you for treatment, payment or health care
operations. 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 necessary for emergency
treatment.
To request restrictions, you must make your request in writing to:
(Your Physician) or
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
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:
(Your Physician) or
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
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. To
obtain a paper copy of this notice, you may access The South Bend Clinic’s
internet site www.southbendclinic.com
and print a copy or contact:
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
CHANGES TO THIS NOTICE
The South Bend Clinic reserves the right to change this notice. The South
Bend Clinic reserves the right to make the revised or changed notice effective
for medical information we already have regarding you as well as any information
we receive in the future. The South Bend Clinic will post a copy of the current
notice throughout the clinic. The notice will contain, on the first page, in the
top center of the page, the effective date.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a
complaint with The South Bend Clinic or with the Secretary of the Department of
Health and Human Services. To file a complaint with The South Bend Clinic,
contact:
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
All complaints must be submitted in writing. You will not be penalized
for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information, not covered by this
notice or the laws that apply to us, will be made only with your written
permission. If you provide us permission to use or disclose medical information
about you, you may revoke that permission, in writing, at any time. If you
revoke your permission, we will no longer use or disclose medical information
about you for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already made with your
permission, and that we are required to retain our records of the care that we
provided to you.
THE SOUTH BEND CLINIC PRIVACY ACKNOWLEDGEMENT
Our Notice of Privacy Practices provides information about how we may use
and disclose protected health information about you or any person for whom you
have legal authority to make health care decisions. You have the right to review
our notice before signing an acknowledgement. As provided in our notice, the
terms of our notice may change. If we change our notice, you may obtain a
revised copy by accessing The South Bend Clinic’s internet site
www.southbendclinic.com and print
a copy or contact the following to request a copy:
Director of Health Information Management
211 North Eddy Street
South Bend,
Indiana
46617
Thank you for allowing The South Bend Clinic the opportunity to assist you
with your medical needs!