NOTICE OF PRIVACY PRACTICES HIPAA

SUBLETTE COUNTY HOSPITAL DISTRICT

PINEDALE MEDICAL CLINIC: 625 E HENNICK ST. PO BOX 627 PINEDALE WY 82941

MARBLETON-BIG PINEY CLINIC: 103 W 3RD ST. PO BOX 787 MARBLETON WY 83113

SUBLETTE COUNTY EMS

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.

OUR PLEDGE REGARDING MEDICAL INFORMATION:  

We understand that medical information about you and your health is personal. We are committed to protecting Protected Health Information (PHI). PHI includes all “individually identifiable health information” that is transmitted or maintained in any form or medium by a Covered Entity. Individually identifiable health information that can be used to identify an individual and that was created, used, or disclosed in (a) the course of providing a health care service such as diagnosis or treatment, or (b) in relation to the payment for the provision of health care services. 

WE ARE REQUIRED BY LAW TO: 

Give you this notice of our legal duties and privacy practices with respect to:                                

•       Medical information about you. 

•       Make sure that medical information that identifies you is kept private. 

•       Follow the terms of the notice that is currently in effect. 

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.  

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, medical students, or other clinic personnel who are involved in taking care of you at the clinic. We also may disclose medical information about you to people outside the clinic who may be involved in your medical care after you leave the clinic.   

FOR PAYMENT. We may use and disclose medical information about you so that the treatment and services you receive at the clinic may be billed to and payment may be collected from you, an insurance company or a third party. 

FOR HEALTH CARE OPERATIONS. We may use and disclose medical information about you for clinic operations. These uses and disclosures are necessary to run the clinic and make sure that all of our patients receive quality care. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes.   

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 the clinic.  1 

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.   

FUNDRAISING ACTIVITIES. Patients have the right to opt out of these communications however, with your prior permission; we may use and disclose medical information about you to contact you in an effort to raise money for the clinic and its operations. 

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. 

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.

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. 

AS REQUIRED BY LAW. We will disclose medical information about you when required to do so by federal, state, or local 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 activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.   

WORKERS’ COMPENSATION. We may release medical information about you for workers’ compensation or similar programs. 

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. 

ORGANIZED HEALTH CARE ARRANGEMENT (OHCA). The Sublette County Hospital District currently participates in an organized health care arrangement (OHCA) with the University of Utah. A list of participants in the OHCA can be found at http://uofuhealth.utah.edu/privacy-office/ohca.php. We do this to support our provision of health care services to underserved patient populations. These OHCA participants share access to the University’s electronic medical record system and may, under certain circumstances, access your medical and billing information for treatment or health care operation’s purposes to improve, manage, and coordinate your care without seeking your advance authorization, but only to the extent permitted by law.

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. We may also release medical information to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.   

MILITARY AND VETERANS. If you are member of the armed forces, we may release medical information about you as required by military command authorities. 

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 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 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. 

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 crime if, under certain 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 clinic; 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. 

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. However, it should be noted that you may not take the actual, physical chart, as it is property of the clinic. We have up to 30 days to make your medical information available to you. 

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. We may deny your request for an amendment under certain circumstances. 

RIGHT TO AN ACCOUNTING OF DISCLOSURES. You have the right to request a list of certain disclosures we made of your medical information for purposes other than treatment, payment and health care operations or for which you provided written authorization.   

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. To request a restriction, you must make your request in writing. 

OUT OF POCKET PAYMENTS. If you paid out of pocket in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations. 

RIGHT TO AN ELECTRONIC COPY OF ELECTRONIC MEDICAL RECORDS. If your Protected Health Information is maintained in an electronic format, you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity.   

RIGHT TO GET NOTICE OF A BREACH. You have the right to be notified upon a breach of any of your unsecured Protected Health Information. 

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 by mail or at work. To request confidential communications, you must make your request in writing. We will accommodate reasonable requests.

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. 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. 

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 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 the clinic. 

FOR MORE INFORMATION OR TO REPORT A PROBLEM, PLEASE CONTACT:

SUBLETTE COUNTY HOSPITAL DISTRICT

Medical Records 

PO BOX 627 

PINEDALE WY 82941