Privacy Practices

Effective Date: April 14, 2003

Notice of Health Information Privacy Practices
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.

Who Will Follow This Notice
This notice describes the practices of Woman’s Hospital and that of:
• any health care professional authorized to enter information into your hospital medical record
• all departments and units of the hospital, including Woman’s Home Care Service Organization
• all employees, staff, volunteers, contractors, and other hospital personnel
• any member of a volunteer group that we allow to help you while you are in the hospital
• any physician who is a member of the Medical Staff and involved in your care
• any hospital personnel who provide health care services for you at any of our satellite locations

In addition satellite locations may share medical information with each other for treatment, payment, or other hospital operational purposes described in this notice.

This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal physician. He or she may have different policies or notices regarding the use and disclosure of your medical information created in the doctor’s office or clinic.

Notice of Organized Health Care Arrangement
The hospital, the independent contractor members of our medical staff (including your physician), and other health care providers affiliated with the hospital have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment, or health care operations. This enables us to better address your health care needs.

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.
• 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.
• follow the terms of the notice that are currently in effect.

Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record serves as a:
• basis for planning your care and treatment
• means of communication among the many health professionals who contribute to your care, e.g. doctors, nurses, technicians, and other hospital personnel
• legal document describing the care you received
• means by which you or a third-party payer can verify that services billed were actually provided
• tool in educating health professionals, e.g. nursing students, social services students, etc.
• source of data for medical research
• source of information for public health officials charged with improving the health of the state or nation, e.g. Bureau of Vital Statistics for births, Department of Health and Hospitals for infectious diseases
• source of data for facility planning and marketing
• tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Your Rights Regarding Medical Information About You
Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. As provided by federal law, specifically 45 CFR 164 STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION; FINAL RULE, you have the right to:
• request a restriction on certain uses and disclosures of your information. In some cases it may not be feasible for us to agree to the requested restriction and by law we are not required to do so
• obtain a paper copy of the Notice of Health Information Practices by request from the hospital’s Health Information Management Department
• inspect and obtain a copy of your health record as also provided in Louisiana law (R.S. 40:1299.96)
• request an amendment to your health record
• obtain an accounting of disclosures of your health information
• request communications of your health information by alternative means or at alternative locations
• revoke in writing your authorization to use or disclose health information except to the extent that action has already been taken.

Woman’s Hospital Responsibilities
Woman’s Hospital is required to:
• maintain the privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice
• notify you if we are unable to agree to a requested restriction or amendment
• accommodate any reasonable request you may have to communicate health information by alternative means or at alternative locations.

Woman’s Hospital will not use or disclose your health information without your authorization, except as provided by law or described in this notice.

Revisions to Privacy Practices
Federal Standards for Privacy of Individually Identifiable Health Information, 45 CFR 164 is effective on or after April 14, 2003. Woman’s Hospital reserves the right to change our practices and to make new provisions effective for all individually identifiable health information we maintain. Should our information practices change, we will make the new version of this Privacy Practices Notice available to you upon request.

For More Information or to Report a Problem
Requests to inspect, copy, or amend medical information must be in writing and submitted to the Director of Health Information Management. Requests for an accounting of disclosures must also be submitted to the Director of Health Information Management. If you have questions and would like additional information, you may contact the Woman’s Hospital Patient Relations Coordinator at 225-231-5555. If you believe your privacy rights have been violated, you can file a formal complaint with the Patient Relations Coordinator or with the Office for Civil Rights, U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

How Woman’s Hospital 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 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.

Pursuant to state and federal law, Woman’s Hospital will use your health information 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 hospital personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for surgery or a delivery may need to know if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital 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 hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy or others we use to provide services that are part of your care.

The retail and infusion pharmacies may disclose medical information related to your prescription medication to physicians or other pharmacies if the prescription is being transferred.

Payment. We may use and/or disclose your health information for the purpose of allowing us, as well as other entities, to secure payment for the health care services provided to you. For example: A bill may be sent to you, an insurance company, or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We may also tell your health plan about a treatment or prescription you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment. Woman’s Home Care assessment data may be transmitted to the Centers for Medicare and Medicaid Services. In the event that payment is not made, we may also provide limited information to collection agencies, attorneys, credit reporting agencies, and other organizations as is necessary to collect for services rendered.

Health Care Operations. We may use and/or disclose your information for the purposes of our day-to-day operations and functions. For example: Members of the medical staff, the Risk or Quality Assessment Director, or members of the Quality Assessment team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may also compile medical information we have and compare it with other hospitals to see how we are doing and 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 learning who the specific patients are.

Business Associates. There are some services provided in our organization through contracts with business associates. Examples include physicians conducting administrative duties (Medical Director), record storage facilities, accreditation organizations (JCAHO), claims processing administrators, record copy services, software and hardware maintenance vendors. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do, which may include billing you, your insurance company or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

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 personal medical information for research, the project will have been approved through this research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project. For example, this type of disclosure would help researchers look for patients with specific medical needs, but the medical information they review does not leave the hospital.

Coroners and Funeral Directors. We may release medical information to a coroner. 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 to funeral directors as necessary to carry out their duties.

Marketing. We may contact you about treatment alternatives or other health-related benefits and services that may be of interest to you. In addition, you may be invited to attend special events and celebrations.

Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or medical care at the hospital.

Fundraising. We may contact you as part of a fund-raising effort.

Food and Drug Administration (FDA). We may disclose to the FDA health information relative to adverse events with respect to food, drugs, supplements, product and product defects, to track FDA related products, to enable product recalls, repairs, or replacement, or to conduct post marketing surveillance.

Public Health. We may disclose medical information about you for public health activities. These activities may include, but are not limited to, the following:
• to prevent or control disease, injury or disability
• to report births and deaths
• to report child or elder 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.

Correctional Institution. Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Legal Proceedings. We may disclose health information in response to a court order or valid subpoena or to our own attorney in defense or in response to a complaint or claim about services rendered.

Law Enforcement. We may disclose health information for law enforcement purposes as required by law.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney; provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients.

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 Situation
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.

Other Permitted Uses and Disclosures That May be Made, With the Opportunity for You to Object
Patient Directory. We may include certain limited information about you in the patient directory. This information may include your name, location in the hospital, your general condition (e.g. fair, stable, 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, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. If you are not provided the opportunity to object to being included in the directory due to emergency treatment circumstances, you will be provided the opportunity when it is feasible to do so.
 
Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Communication With Family. Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

If you do not wish hospital personnel to have contact or communicate with your family, you may inform us of your objection.
 
Other Authorized 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 authorization. If you authorize us to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization we will no longer use or disclose medical information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you.