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HIPAA Forms: Authorization Form Authorization Form - Radiology Confirmation of Receipt of Notice of Privacy Practice

Notice of 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.

This notice describes the privacy practices of Memorial Hospital and those who provide services to patients at this hospital. (Hereafter referred to as we.)

Patient Health Information
Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment and related medical information. Your health information also includes payment, billing and insurance information.

How We Use Your Patient Health Information
We use health information about you for treatment, to obtain payment, and for our health care operations, including administrative purposes and evaluation of the quality of care that you receive. Under some circumstances, we may be required to use or disclose the information even without your authorization.

Selected Examples of Treatment, Payment, and Health Care Operations
Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care. We may also disclose information to someone who helps pay for your care.

We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payments from your health plan or to a friend or family member involved in or responsible for payment of your medical care.

Health Care Operations:
We will use and disclose your health information to conduct our standard internal operations including, but not limited to, proper administration of records, evaluation of the quality of treatment, and to assess the care and outcomes of your case and others like it.

Other Uses and Disclosures
We may use or disclose identifiable health information about you for other reasons, even without your written authorization.. Subject to certain requirements, we are permitted to give out health information without your written authorization for the following purposes:

Required by Law: We may be required by law to report gunshot wounds, suspected abuse or neglect, or similar injuries and events.

Public Health Activities: As required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.

Health Oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.

Judicial and Administrative Proceedings: We may disclose information in response to an appropriate subpoena, court order or search warrant.

Law Enforcement Proceedings: Subject to certain restrictions, we may disclose information required by law enforcement officials.

Deaths: We may report information regarding deaths to coroners, medical donation agencies, examiners, funeral directors and organ donation agencies.

Serious Threat to Health or Safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Incidental Uses
We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Military and Special Government Functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes.

Research: We may use or disclose information for approved medical research.

Worker’s Compensation: We may release information about you for worker’s compensation or similar programs providing benefits for work-related injuries or illnesses.

Fundraising: You are entitled to opt out of fundraising communications at any time with written authorization.

If you are an inpatient at Memorial Hospital we may ask you for your permission to disclose limited information about you to clergy or include it in the Hospital Patient Directory. The information included would be your name, location in the hospital and religious affiliation. You may choose to limit part or all the information or choose not to be included in the clergy listing or Hospital Patient Directory. We may also tell family or friends your general condition and that you are a patient at Memorial Hospital if they inquire.

Under limited circumstances, we may disclose information to notify or locate your relatives or to assist disaster relief agencies.

In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization, you can later revoke that authorization to stop any future uses and disclosures.

Individual Rights
You have the following rights with regard to your health information. Please contact the Contact Person listed to obtain the appropriate forms for exercising these rights.

Request Restrictions: You may request restrictions on certain uses and disclosures of your health information. We are not required to agree with such restrictions, but if we do agree, we must abide by those restrictions.

Confidential Communications: You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.

Inspect and Obtain Copies: In most cases, you have the right to look at or get a copy of your health information. There may be a charge for the copies. You have the option to also request an electroinic copy of your health information.

Amend Information: If you believe that information in your record is incorrect, or if important information is missing, you have the right to request that we correct/amend the existing information or add the missing information.

Accounting of Disclosures: You may request a list of instances where we have disclosed health information about you for reasons other than treatment, payment or health care operations or for which you have signed an authorization.

HITECH ACT: Under the HITECH ACT, any individual who wishes to pay for a service out of pocket may elect not to have that information sent to the Health Plan. Written authorization needs to be obtained.

Omnibus Rule: The Onmibus rule states that an individual has the right to receive notifications whenever a breech of his/her unsecured PHI (Protected Health Information) occurs.

Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the notice currently in effect.

Changes in Privacy Practices
We may change our policies at any time and post the new Notice in the Admissions/Registration area and on our website. All changes in the notice will be effective for all personal health information we maintain even that collected under prior policies. You can also request a copy of our Notice at any time. For more information about our privacy practices, contact the Contact Person listed below.

Complaint Process
If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services and/or the Contact Person listed below. You will not be penalized in any way for filing a complaint.

Contact Person
If you have any questions, requests, or complaints, please contact:

Jill Vough, Privacy Officer
Memorial Hospital
91 Hospital Drive
Towanda, PA 18848
Telephone: 570-268-2215

Independent Contractors
Memorial Hospital and those who provide services to patients at Memorial Hospital are independent contractors and do not assume any liability for the services or conduct of each other.

Effective Date:
The effective date of this Notice is: April 14, 2003.
Approved by HIPAA Committee 03/19/03
Date Approved: March 19, 2003, revised September 17, 2013