NOTICE OF INFORMATION PRACTICES
Roper Hospital / Bon Secours St. Francis Hospital / Mount Pleasant Hospital
Effective Date: April 14, 2003
Revised: May 1, 2009
This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that information about you and your health is personal. We are committed to protecting your health information. We will create a record of the care and services you receive at the Roper St. Francis Healthcare (RSFH), its subsidiaries and other entities. We need this record to provide you with quality care and to comply with certain legal requirements. This record will be available to all physicians who may be treating you at any of RSFH’s facilities.
This notice will tell you about the ways we may use and disclose your health information. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.
We are required by law to:
Ensure the health information that identifies you is kept private.
Provide you with this notice as to our legal duties and privacy practices with respect to your health information.
Follow the terms of the notice.
WHO WILL FOLLOW THIS NOTICE?
This notice describes RSFH’s practices and that of:
Any health care professional authorized to enter information into your medical record, including doctors on our medical staff.
All departments and units of RSFH.
All employees, staff, volunteers and other RSFH personnel.
In addition, these RSFH facilities may share health information with each other for treatment, payment or healthcare operations purposes as described in this notice.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe the different ways we may use and disclose health information. For each category of uses or disclosures, we will explain what is meant and provide 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 at least one of the categories.
For Treatment. Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team record the actions they take and their observations. That way the physician will know how you are responding to treatment.
We will also provide other physicians or a subsequent healthcare provider with copies of various reports that should assist in arranging your care and treating you once you are discharged from our care. These independent physicians and healthcare professionals constitute an organized health care arrangement under certain laws governing the privacy of health information only. These individuals are otherwise independent practitioners and are not agents of any of our facilities.
For Payment. We may use and disclose your health information so the treatment and services provided by RSFH may be billed and payment may be collected from you, an insurance company or a third party. For example, we may tell your insurance company about a treatment you are going to receive to obtain prior approval or to determine whether your insurance will cover the treatment. We may also need to give your insurance company information about a surgery you had at a RSFH facility so that your insurance company will pay us or reimburse you for the surgery.
For Health Care Operations. We may use and disclose your health information for healthcare operations. This is necessary to run RSFH and give quality care to our patients. For example, we may use health information to review the treatment and services provided to you, and to evaluate the performance of our staff in caring for you. We may also combine health information about many RSFH patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may disclose information to doctors, nurses, technicians and other personnel for review and learning purposes.
Appointment Reminders. We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at RSFH.
Treatment Alternatives. We may use and disclose health 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 health information to tell you about health-related benefits or services that may be of interest to you.
Business Associates. There are some services RSFH provides through contacts with business associates. Examples include but are not limited to certain laboratory and radiology tests, and medical record copying services. For example, we may use a copy service to make copies of your medical record. When we hire companies to perform these services, we may disclose your health information so that they can perform the job we’ve asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your health information.
Fundraising Activities. We may use your health information to contact you in an effort to raise money for RSFH and its operations. We would only release contact information, such as your name, address and phone number and the dates you received treatment or services. If you do not want RSFH to contact you for fundraising efforts, you must notify the RSFH Privacy Officer in writing.
Hospital Directory. Unless you notify us that you object, we may include certain limited information about you in the RSFH hospital directory while you are a patient. This information may include your name, location in the hospital, your general condition (e.g., good, fair, serious, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy affiliated with your faith, such as a priest or rabbi. If you do not want to be included in the hospital directory you must notify us in writing using our patient consent form.
Individuals Involved in Your Care or Payment for Your Care. We may release your health information to a family member, other relative, close personal friend or any other person who is involved in your care or payment related to your care.
Research. We may disclose information to researchers when their research has been approved by an institutional review board who has reviewed the research proposal and established protocols to ensure the privacy of your health information.
To Avert a Serious Threat to Health or Safety. We may use and disclose your health information 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 or reduce the threat.
South Carolina Department of Health and Environmental Control (DHEC). As required by law, we may disclose your health information to DHEC as it relates to licensing inspections or other requests for reviews by DHEC.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As required by accreditation, we may disclose your health information to the JCAHO at the time of their surveys.
Disaster Relief. We may release your health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Organ and Tissue Donation. We may release health 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 your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation. We may release your health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Public Health Risks. We may disclose your health information 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 child 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 an adult 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 your health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute.
Law Enforcement. We may release health 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 RSFH.
- 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 health 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 health information to funeral directors as necessary for them to carry out their duties.
National Security and Intelligence Activities. We may release your health information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. We may also disclose your health information 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 your health information 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; (3) for the safety and security of the correctional institution.
Blood Testing. While you are receiving care, a health care worker may accidentally be exposed to blood or other body fluids. If this occurs, your blood will be tested for the presence of certain diseases (for example, HIV, Hepatitis B and C). These tests are necessary to help protect the health care worker. The results of these tests will be a part of your medical record and will not be released except with your prior consent or as required or permitted by law.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health 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 your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information 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. We are required to retain records of the care that we provided to you.
South Carolina Law. In the event that South Carolina Law requires us to give more protection to your health information than stated in this notice or required by Federal Law, we will give that additional protection to your health information. In addition, state law mandates regarding medical record retention periods may be more stringent than federal law. Please be aware that any request or release of PHI must be considered on a case-by-case basis. If you desire further information about specific state laws and regulations that may not be preempted by HIPAA, please contact the RSFH Legal Department.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Right to Inspect and Copy. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually this includes medical and billing records, but may not include psychotherapy notes or psychiatric/substance abuse notes.
To inspect and copy health information, you must sign an Authorization to Release the Information Form which can be obtained in the Medical Record department of the appropriate RSFH treatment facility. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
Right to Request an Amendment. If you feel that health 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 RSFH.
To request an amendment, your request must be made in writing to the Director of Medical Records at the appropriate RSFH treatment facility. 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 health information kept by or for RSFH.
- Is not part of the information which you would be permitted to inspect and copy.
- Is accurate and complete.
Right to Request an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made concerning your health information; but does not include disclosures made for treatment, payment, or for healthcare operations, or for purposes or disclosures specifically authorized by you.
To request this list or accounting of disclosures, you must submit your request in writing to the RSFH Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. 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. The list will include the date of the disclosure, to whom health information was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health 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 health 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. To request restrictions, you must make your request in writing. 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.
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. You may not limit uses and disclosures that we are legally required or allowed to make.
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 at home, or send billing information to an alternative billing address. To request confidential communications, you must notify us in writing using our patient consent form. 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 obtain a copy of this notice at any time from our website, www.rsfh.com, or from the RSFH facility where you obtained treatment.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. The notice will contain the effective date on the first page. You can view the current notice at our website, www.rsfh.com.
If you believe your privacy rights have been violated, you may file a complaint with RSFH or with the Secretary of the Department of Health and Human Services.
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact our Privacy Officer at (843) 789-1778. You will not be penalized for filing a complaint.