Effective Date: April 14, 2003

If you have any questions about this notice, please contact
Mountain States Health Alliance Corporate Compliance Department
Phone:  423-431-5716.

WHO WILL FOLLOW THIS NOTICE

Mountain States Health Alliance provides services to our patients in partnership with other healthcare professionals. The information privacy practices in this notice will be followed by:

• All MSHA facilities which include Johnson City Medical Center; Indian Path Medical Center; Indian Path Pavilion; Johnson City Specialty Hospital; North Side Hospital; James H and Cecile C Quillen Rehabilitation Hospital; Smyth County Community Hospital; Sycamore Shoals Hospital; Johnson County Community Hospital, Kingsport Ambulatory Surgery Center and Woodridge Hospital.
   

• All departments and units of MSHA, including Skilled Nursing Facilities, Home Health, Hospice.
   

• Health care professional and others who may be involved directly or indirectly in your care such as employees, physicians, residents, students, volunteers, business associates affiliated with MSHA, others.

OUR PLEDGE TO YOU

We understand that medical information about you is personal. MSHA is committed to insuring confidentiality and safeguards to protect your information. We create a record of the care and services you receive; and use this record to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain. Your personal doctor may have different policies or notices regarding the use and disclosure of your medical information created in the doctor's office. This notice will tell you about the ways in which we may use and disclose medical information about you; and describes your rights 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; to give you this notice of our privacy practices; and to follow the terms of the notice that is currently in effect.  (Top)

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

• We may use medical information about you to provide medical treatment or services. We may disclose your medical information to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in your care. For example, a doctor treating you for a broken leg may need to know if you have diabetes. The doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. We may use and disclose medical information about you to obtain payment for treatment provided. For example, we may give your health plan information about services you received so your health plan will provide payment.
   

• We may 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 treatment. We may use and disclose medical information about you for hospital operations. For example, we may send you a survey asking about the care you received as a patient at MSHA. We may use your information to evaluate the performance of our staff. We may combine medical information about many hospital patients to decide what services we should offer and whether certain new treatments are effective. We may disclose information to doctors, nurses, medical students, and other hospital personnel for learning purposes.
   

• We may contact you for appointment reminders or to tell you about possible treatment options, alternatives or other health related benefits/services that may be of interest to you. We may disclose medical information to the Mountain States Health Foundation so that the foundation may contact you regarding fundraising activities on behalf of MSHA. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the hospital.
   

• We may include certain information about you in the hospital 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 MSHA clergy even if they don’t ask for you by name. You may request not to be included in our hospital directory.
  
  We may release medical information about you to a friend or family member who is involved in your medical care unless you request a restriction to such releases. We may give information to someone who helps pay for your care. 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.
   

• We may use or disclose medical information about you for several other reasons; some of which can be without your prior authorization subject to certain requirements or legal obligations; others may require your authorization. You may revoke an authorization, in writing, unless we have taken action in reliance upon your prior authorization. Reasons for other uses and disclosures include: when required by federal or state law; to avert a serious threat to health or safety of the public or another person; to authorized federal officials for intelligence and national security activities; to authorized federal officials in order to protect the President and other authorized persons or foreign heads of state or conduct special investigations; as required by military authorities if you are a member of the armed forces; in response to a court or administrative order, subpoena or other lawful process; to law enforcement officials in response to a court order, subpoena or similar process to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime; about a death believed to 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; to report child/elder abuse or neglect or domestic violence; if you are an inmate, your information may be released to a correctional institution to provide you with health care; to protect your health and/or the health and safety of others; or for the safety and security of the correctional institution.

Additional reasons include: to an organ donation bank to facilitate organ or tissue donation and transplantation; to workers' compensation or similar programs for work-related injuries or illness; for public health activities such as to prevent or control disease, injury or disability; to report births and deaths; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease; to health oversight agencies for activities such as 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; to a coroner or medical examiner to identify a deceased person or determine the cause of death and to funeral directors as necessary to carry out their duties; for research purposes. For example, a research project may involve comparing the health of all patients who received one medication to those who received another, for the same condition. All research projects are subject to a special approval process. Before we use or disclose the medical information, the project will have been approved through this research approval process.  (Top)

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

• Right to Inspect and Copy. You have the right to request to inspect and copy medical information that may be used to make decisions about your care. There may be exceptions to this such as access to psychotherapy notes, information compiled in anticipation of or for use in civil, criminal or administrative proceedings or information that may be governed by other regulations such as the Clinical Laboratory Improvement Act. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Medical Records Department of the facility. There may be fees 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. Examples of these circumstances include if the information was obtained under a promise of confidentiality; if access to the information in question is reasonably likely to endanger the life and safety of you or anyone else; if the information makes reference to another person and your access would likely cause harm to that person or if you are an inmate of a correctional facility. If you are denied access to medical information, you may request that the denial be reviewed.
   

• Right to Amend. If you feel that medical information we have about you is incorrect, 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 the hospital. To request an amendment, your request must be made in writing and submitted to the Medical Records Department of the facility. We may deny your request for an amendment if it is not in writing. In addition, we may deny your request if you ask us to amend information that was not created by us; is not part of the medical information kept by or for the hospital; 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. This accounting will not include disclosures made for: purposes of treatment, payment or health care operations; made to you or authorized by you; from our facility directory; to persons involved in your care; for national security purposes; relating to inmates; incidental purposes; or related to a limited data set. To request this list or accounting of disclosures, you must submit your request in writing to the Medical Records Department of the facility. Your request must state a time period that 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.
   

• Right to Request Restrictions/ Confidential Communications. You have the right to request a restriction on the medical information we use or disclose about you for treatment, payment or health care operations. For example, you may request that your information not be included in our facility directory. 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 instead of at home. Your request must be in writing. It may be submitted at the time of registration or during your hospital stay. We are not required to fulfill all requests for restrictions or confidential communications. We will review your request and attempt to accommodate all reasonable requests.
   

• 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. You may also obtain a copy of this notice at our website, www.msha.com.  (Top)

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 each MSHA facility. The effective date is noted on the first page. In addition, each time you register with one of our hospitals for treatment or health care services, we will offer you a copy of the current notice.  (Top)

COMPLAINTS

• If you have questions, would like additional information or believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact our Corporate Compliance Department at (423) 431-5716. To file a written complaint with the Department of Health and Human Services, you may contact our Corporate Compliance Department for more information. There will be no retaliation against you for filing a complaint.  (Top)

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. (Top)

 Mountain States Health Alliance
400 North State of Franklin Johnson City, TN 37604

Back

Copyright © Mediserve Medical Equipment 2006