Notice of Privacy Practices For Protected Health Information (PHI)
THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU OR ABOUT THE INDIVIDUAL FOR WHOM YOU ARE AN AUTHORIZED PERSONAL REPRESENTATIVE MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY.
Ellisville State School is dedicated to protecting your medical information. We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information.
Ellisville State School collects health information from you and stores it in a chart or file and on a computer. This is your health record. The health record is the property of Ellisville State School, but the information in the record belongs to you. If you have questions about any part of this Notice or if you want more information about the privacy practices at Ellisville State School, please contact:
Privacy Officer Phone number: 601-477-6382
Ellisville State School
1101 Highway 11 South
Ellisville, MS 39437
Effective Date of this Notice: April 14, 2003.
Ellisville State School is required to abide by the terms of the Notice currently in effect.
Changes to the Notice: Ellisville State School reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. If Ellisville State School makes a material change in this Notice, we will post the revised Notice at the facility and will make a copy of the revised Notice available to you upon request.
Section I: Description of how Ellisville State School may use or disclose your health information and examples of each.
The law permits Ellisville State School to use or disclose your health information without your written consent or authorization for the following purposes:
Treatment: We may use health information about you to provide treatment and services. We may disclose your health information to doctors, nurses, technicians, or other staff at Ellisville State School who are involved in taking care of you or when we refer you to another health care provider for treatment or services.
Examples: Your physician may ask a nurse to give you certain medications or information related to your condition or treatment. Another example is that if you had heart problems that required us to consult with a heart specialist (cardiologist) outside of the center, your doctor at the facility may refer you to a cardiologist in the community for your care. The facility would share information from your health record needed by the staff at the cardiologist’s office for your continued care. We may also release your information to another treatment facility for your continued care after your discharge from this facility.
Payment: We may use and disclose your health information to third party payers, such as insurance companies, Medicaid, or Medicare, when needed to determine your eligibility for benefits, for reimbursement, or for other requirements related to payment for treatment or services.
Examples: Information on or accompanying a bill to your insurance company or a claim form to the Division of Medicaid may include information, such as your diagnosis, the dates you received the services for which payment is requested or claimed, and the procedures or services you received. Information may be disclosed and used as part of utilization review activities, such as pre-certification and preauthorization of services and concurrent and retrospective review of services.
Healthcare Operations: We may use your health information for the purposes of Ellisville State School’s operations. These uses and disclosures are necessary to run or operate the facility and to make sure that all individuals we serve receive quality care.
Examples: Your records may be copied by a secretary to send them to another healthcare provider for your continued treatment. Members of the medical/nursing staff and other staff at the facility may review your health information to assess the care, outcomes, and quality of services you and others at the facility receive.
Section II: Other purposes for which we are permitted or required to use or disclose your health information without your consent or authorization:
1. We may contact you to provide or remind you of an appointment, information about treatment alternatives, or other health related benefits and services that may be of interest to you. Examples of how we may contact you include:
- Telephone calls (Messages to call the facility may be left on an answering machine)
- Written correspondence
- Facsimile (fax)
- Electronic mail
- Written correspondence or telephone calls asking you to help identify what services might be beneficial to you, to ask about your satisfaction with our services, or to ask about your ongoing treatment after discharge.
2. We may disclose your health information to you or your authorized personal representative, except as restricted under applicable laws and regulations.
3. Information may be released about you for public health activities, such as:
- To prevent or control diseases.
- To report death.
- To report abuse or neglect.
- To track products as regulated by the federal Food and Drug Administration (FDA) and to report problems or reactions to medications or products.
- To provide notification and communication about product recalls, replacements and look-backs.
4. Information may be released to health oversight agencies for activities authorized by law. These activities may include investigations, inspections and licensure, and other lawful activities. These activities may also include providing access to your health information on a need-to-know basis by members of the Human Rights Advocacy Committee for approved activities. All specific information gained by the Human Rights Committee shall remain confidential.
5. Information may be disclosed in the course of any administrative or judicial proceeding:
1. In response to a court order.
2. Under certain restricted circumstances, in response to a subpoena or a similar process.
6. Information may be disclosed for law enforcement purposes under certain circumstances, such as reporting of certain types of physical injuries, locating persons, and reporting and investigating of crimes.
7. Information may be disclosed to a coroner, medical examiner, or funeral directors, consistent with applicable law.
8. If you are an organ, eye or tissue donor, your health information may be disclosed to organizations involved in procurement, banking or transplantation to facilitate organ, eye or tissue donation or transplantation.
9. Information may be disclosed for public safety reasons to appropriate persons in order to prevent or lessen a serious and/or imminent threat to the health or safety of a particular person or the general public.
10. Information may be disclosed as necessary to comply with Workers Compensation laws.
11. Information may be disclosed for research purposes, only as approved by the facility’s research committee that serves as an Institutional Review Board and/or privacy board.
12. We may disclose your health information for other purposes as required or permitted by law.
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Section III: Other Uses or Disclosures
Unless you object or we are otherwise restricted by law, we may disclose relevant health information about your location, your general condition, or in the event of your death, if it is needed to notify or assist in notifying a family member, your authorized personal representative or another person responsible for your care.
If you are available and able to agree or object prior to our disclosing this information, we will provide you the opportunity to object or otherwise obtain your agreement prior to disclosing the information. If you are unable or unavailable to agree or object, our health professionals will use their best judgement to determine if disclosing the information to your family member or others involved in your care is in your best interest. If they decide that disclosure is in your best interest, they will disclose only the health information that is relevant and necessary to that person’s involvement in your care.
Section IV: When Ellisville State School may not use or disclose your health information.
Except as provided in this Notice of Privacy Practices, Ellisville State School will not use or disclose your health information, including, except under certain conditions, psychotherapy notes, without your written authorization. If you do authorize the facility to use or disclose your information for purposes other than as provided in this Notice, you may revoke your authorization in writing at any time.
Section V: Your Health Information Rights
You have the following rights with respect to your Protected Health Information (PHI):
1. The right to request restrictions on certain uses and disclosures of protected health information.
Ellisville State School is not required to agree to your requested restriction. If the facility does agree to your requested restriction, we will comply with your request, unless the information is needed to provide you with emergency treatment.
2. The right to receive confidential communications of protected health information.
You have the right to request in writing to the Privacy Officer that the facility only communicate to you in a certain format (for example, in writing) and/or at a certain location (for example, only at your work address). We will accommodate all reasonable requests.
3. The right to inspect and copy protected health information, subject to certain restrictions as provided for by law. You may be charged a fee for copying and/or postage.
4. The right to amend protected health information. You have a right to request that Ellisville State School amend or change your health information. Ellisville State School is not required to change your health information under certain conditions. You must make requests for amendments in writing and include the reason(s) for your request.
5. The right to receive an accounting of disclosures of protected health information. You have a right to receive an accounting of disclosures of your health information made by the facility, except for disclosures such as treatment, payment, healthcare operations, and certain other disclosures as provided for by law.
6. The right to receive a paper copy of this Notice of Privacy Practices. If you agreed to receive this Notice electronically, you also have the right to request a paper copy.
Section VI: How you can exercise your health information rights.
You may exercise one or more of the rights described in this Notice or receive additional information by contacting:
Privacy Officer Phone: 601-477-6382
Ellisville State School
1101 Highway 11 South
Ellisville, MS 39437
Section VII: Complaints
If you believe your health information privacy rights have been violated, you may contact:
Privacy Officer Phone: 601-477-6382
Ellisville State School
1101 Highway 11 South
Ellisville, MS 39437
Or, you may contact:
OCR Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 515 F HHH Building
Washington, D.C. 20201
You will not be retaliated against for filing a complaint
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