Notice of Privacy Practices
Effective Date of This Notice: 04/14/03
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.
Keefe Memorial Hospital is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at Keefe Memorial Hospital, please contact:
Rachel Turner – Privacy/Security Officer – 719-767-5661
WHO WILL FOLLOW THIS NOTICE
This notice describes our hospital’s practices and that of:
- Any healthcare professional authorized to enter information into your hospital chart
- All departments of the hospital
- Any member of a volunteer group we allow to help you while you are in the hospital
- All employees, staff and other hospital personnel
Keefe Memorial Hospital includes the following entities:
- Keefe Memorial Hospital
- Prairie View Clinic
- Kit Carson Clinic
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. We create a record of the care and services you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the hospital, whether made by the hospital personnel or your personal doctor or other practitioners involved in your care.
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; and follow the terms of the notice that is currently in effect.
HOW KEEFE MEMORIAL HOSPITAL MAY USE OR DISCLOSE YOUR HEALTH INFORMATION
Keefe Memorial Hospital collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of Keefe Memorial Hospital, but the information in the medical record belongs to you. Keefe Memorial Hospital protects the privacy of your health information. The law permits Keefe Memorial Hospital to use or disclose your health information for the following purposes:
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, health care students, clergy, or others who are involved in your care. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also 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 long term care facilities or others we or your physician uses to provide services that are part of your care.
For Payment – We may use and disclose medical information about you so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a service you received at the hospital so your health plan will pay us or reimburse you for the services rendered. We may also 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.
For Regular Health Care Operations – We may use and disclose medical information about you for hospital operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you, or our designee may send you a patient satisfaction survey. We may also combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, health care students and other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare 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.
Information provided to you
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 hospital or clinic.
Health-related Benefits and Services – We may use and disclose medical information to tell you about health-related benefits, services or medical education classes that may be of interest to you.
Directory – We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, where you are located in the hospital, your facility status (Acute Care, Observation Bed, Swing Bed) 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 pastor, 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 do not want us to list this information in our directory and provide it to clergy and others, you must tell us that you object. 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.
Notification and communication with family – We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. We may also give information to someone who helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
Required by law – We will disclose medical information about you when required to do so by federal, state or local law.
Public health – As required by law, we may disclose your health information to public health authorities for purposes related:
to preventing or controlling disease, injury or disability;
to reporting births and deaths;
to reporting child abuse or neglect;
to reporting to the Food and Drug Administration problems with products and reactions to medications;
to notifying people of recalls of products they may be using;
to notifying the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence;
to notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
Health oversight activities – We may disclose your health information to health oversight agencies for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure and other proceedings. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
Judicial and administrative proceedings – We may disclose your health information in the course of any administrative or judicial proceeding.
Law enforcement – We may release medical information if asked to do so by a law enforcement official:
to identifying of locating a suspect, fugitive, material witness or missing person;
in response to a court order, subpoena, warrant, summons or other law enforcement purposes;
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 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.
Coroners, Medical Examiners and Funeral Directors – We may release medical information to coroners, medical examiners and funeral directors. 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.
Organ donation – We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
Research – Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve the treatment of patients with a particular disease or condition. All research projects, however, are subject to a special approval process. We will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.
Public safety – We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
Specialized government functions – We may disclose your health information for military or national security activities authorized by law. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or the law enforcement official.
Worker’s compensation – We may disclose your health information as necessary to comply with worker’s compensation laws. These programs provide benefits for work-related injuries or illness.
Fund-raising Activities – We may use information about you to contact you in an effort to raise money for the hospital and its operations. We may disclose information to a foundation related to the hospital so that the foundation may contact you in raising money for the hospital. We would only release contact information, such as your name, address and phone number. If you do not want the hospital to contact you for fundraising efforts, you must notify our Privacy Officer in writing.
WHEN KEEFE MEMORIAL HOSPITAL MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION
Except as described in this Notice of Privacy Practices, Keefe Memorial Hospital will not use or disclose your health information without your written authorization. If you do authorize Keefe Memorial Hospital to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
[Note: Each of these rights should be explained in enough detail so that the individual understands that each right is not absolute and is subject to some limitations and conditions. While some of these rights have been expanded to include the basic limitations provided under the law, each should be considered in light of the permitted conditions under the law and the organization’s actual practices.]
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 your health information. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, contact the Health Information Management Department at (719) 767-5662, ext 2001. If you request a copy of the information, we will charge a fee 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. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend – You have a right to request that Keefe Memorial Hospital amend your health information that is incorrect or incomplete. 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 Director of Health Information Management. 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 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 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 healthcare operations. You also have the right to request a limit on the medical 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.
We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Director of Health Information Management.
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, disclosure to your spouse.
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.
To request confidential communications, you must make your request in writing to the Director of Health Information Management. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to an Accounting of Disclosures – You have a right to request an “accounting of disclosures” of your health information made by Keefe Memorial Hospital. This is a list of the disclosure we made of medical information about you to others except for purposes of treatment, payment, healthcare operations, information provided to you, directory listings and certain government functions identified above.
To request this list or accounting of disclosure, you must submit your request in writing to the Director of Health Information Management. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list. For example, on paper. 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 Paper Copy of This Notice – You have the right to a paper copy of this privacy notice. You may ask us to give you a copy of this privacy notice at any time by requesting a copy from any member of our hospital personnel.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact:
CHANGES TO THIS NOTICE OF PRIVACY PRACTICES
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 hospital. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition each time you register at or are admitted to the hospital for treatment or healthcare services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may contact or submit your complaint in writing to:
Keefe Memorial Hospital
PO Box 578
Cheyenne Wells, CO 80810
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
You may also address your compliant to one of the regional Offices for Civil Rights. A list of these offices can be found online at http://www.hhs.gov/ocr/regmail.html.
THE QUALITY OF YOUR CARE WILL NOT BE JEOPARDIZED NOR WILL YOU BE PENALIZED FOR FILING A COMPLAINT.
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.
Keefe Memorial Hospital complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Keefe Memorial Hospital does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Keefe Memorial Hospital:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact
Ginny Hallagin, CEO.
Po Box 578
Cheyenne Wells, CO 80810,
If you believe that Keefe Memorial Hospital has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Ginny Hallagin, CEO.
Po Box 578 Cheyenne Wells, CO 80810,
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Ginny Hallagin is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to:
Consumer Response Center, Room 130-A
Federal Trade Commission
600 Pennsylvania Ave. N.W.
Washington, D.C. 20580.
SUMMARY OF YOUR RIGHTS
- You must be told if information in your file has been used against you. Anyone who uses a credit report
or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse
action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the
- You have the right to know what is in your file. You may request and obtain all the information about you in the
files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may
include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
- a person has taken adverse action against you because of information in your credit report;
- you are the victim of identify theft and place a fraud alert in your file;
- your file contains inaccurate information as a result of fraud;
- you are on public assistance;
- you are unemployed but expect to apply for employment within 60 days.
In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each
nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.
- You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness
based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create
scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage
transactions, you will receive credit score information for free from the mortgage lender.
- You have the right to dispute incomplete or inaccurate information. If you identify information in your file
that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your
dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.
- Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable
information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days.
However, a consumer reporting agency may continue to report information it has verified as accurate.
- Consumer reporting agencies may not report outdated negative information. In most cases, a
consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are
more than 10 years old.
- Access to your file is limited. A consumer reporting agency may provide information about you only to people with a
valid need — usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA
specifies those with a valid need for access.
- You must give your consent for reports to be provided to employers. A consumer reporting agency may
not give out information about you to your employer, or a potential employer, without your written consent given to the
employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.
- You may limit “prescreened” offers of credit and insurance you get based on information in
your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you
can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the
nationwide credit bureaus at 888-5-OPT-OUT (888-567-8688) or www.optoutprescreen.com.
- You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer
reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or
- Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may
have more rights under state law. For more information, contact your state or local consumer protection agency
or your state Attorney General Federal enforcers are:
|TYPE OF BUSINESS:||CONTACT:|
|Consumer reporting agencies, creditors and others not listed below||Federal Trade Commission: Consumer Response Center — FCRA|
Washington, DC 20580 1-877-382-4357
|National banks, federal branches/agencies of foreign banks (word “National” or initials “N.A.” appear in or after bank’s name)||Office of the Comptroller of the Currency|
|Compliance Management, Mail Stop 6-6||Washington, DC 20219 800-613-6743|
|Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)||Federal Reserve Board|
Division of Consumer & Community Affairs
Washington, DC 20551 202-452-3693
|Savings associations and federally chartered savings banks (word “Federal” or initials “F.S.B.” appear in federal institution’s name)||Office of Thrift Supervision|
Washington, DC 20552 800-842-6929
|Federal credit unions (words “Federal Credit Union” appear in institution’s name)||National Credit Union Administration|
1775 Duke Street
Alexandria, VA 22314 703-519-4600
|State-chartered banks that are not members of the Federal Reserve System||Federal Deposit Insurance Corporation|
Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638 1-877-275-3342
|Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission||Department of Transportation, Office of Financial Management|
Washington, DC 20590 202-366-1306
|Activities subject to the Packers and Stockyards Act, 1921||Department of Agriculture Office of Deputy Administrator — GIPSA|