Privacy Policies / Disclaimers
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Notice of Privacy Practices for CHRISTUS® Trinity Mother Frances Health System
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW IT CAREFULLY. It addresses the privacy practices of the CHRISTUS® Trinity Mother Frances Health System (“TMFHS”). TMFHS includes all CHRISTUS® Trinity Clinic locations, CHRISTUS® Mother Frances Hospital Regional Health Care Center in Tyler, CHRISTUS® Mother Frances Hospital—Jacksonville, and CHRISTUS® Mother Frances Hospital—Winnsboro, the outpatient departments of those entities, and the employees and physicians who provide you with care or services at any of our locations. We may share health information about you with each other, in electronic or paper form, as necessary to provide you with treatment or health care services, obtain payment for services, or for our joint health care operations, all of which are described in more detail in this notice.
A. We Are Required By Law To Maintain The Privacy Of Your Protected Health Information
We protect the privacy of any information about health status, provision of health care, or payment for health care that can be linked to a specific individual. We refer to such information as “Protected Health Information” or “PHI.”. We are giving you notice of our legal duties and privacy practices concerning PHI.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:
- Posting the revised notice in our physician offices, hospital admitting areas, outpatient clinic locations, and emergency services locations;
- Making copies of the revised notice available upon request at the above locations or through the Privacy Officer’s Office; and
- Posting the revised notice on our website.
B. We May Use And Disclose PHI About You Without Your Authorization In The Following Circumstances
1. We may use and disclose PHI about you to provide health care treatment to you.
We may use and disclose PHI about you to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another health care provider either inside or outside the Trinity Mother Frances Health System.
Mother Frances Hospital 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. Departments of the hospital may also need to share your PHI in order to coordinate different services you may need, such as prescriptions, lab work and x-rays. We may also disclose PHI about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as home health providers or others who may provide services that are part of your care.
CHRISTUS® Trinity Clinic Physician Practice Example: Your doctor may share medical information about you with another health care provider. For example, if you are referred to another doctor, that doctor will need to know if you are allergic to any medications. Similarly, your doctor may share PHI about you with a pharmacy when calling in a prescription.
2. We may use and disclose PHI about you to obtain payment for services.
Generally, we may use and provide your medical information to others to bill and collect payment for the treatment and services provided to you. Before you receive scheduled services, we may share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services.
EXAMPLE: We may need to give your health plan(s) information about your condition, supplies used (such as crutches or other equipment), and services you received (such as x-rays or surgery). The information is given to our billing department and your health plan so we can be paid or you can be reimbursed.
3. We may use and disclose your PHI for health care operations.
We may use and disclose PHI in performing business activities, which we call “health care operations”. These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. For example, we may use or disclose PHI about you for “health care operations” if we are conducting activities designed to improve health care and lower costs for groups of people who have similar health problems and to help manage and coordinate the care for these groups of people. Or, we may use PHI to identify groups of people with similar health problems to give them information designed to improve their health.
4. We may use and disclose PHI under other circumstances without your authorization.
We may use and/or disclose PHI about you for a number of circumstances in which you do not have to consent, give authorization, or otherwise have an opportunity to agree or object. Those circumstances include:
- When the use and/or disclosure is required by law. For example, when a disclosure is required in a federal, state, or local judicial or administrative proceeding.
- When the use and/or disclosure is necessary for public health activities. For example, we may disclose PHI about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
- When the disclosure relates to victims of abuse, neglect, or domestic violence.
- When the use and/or disclosure is for health oversight activities. For example, we may disclose PHI about you to a state or federal health oversight agency which is authorized by law to oversee our operations.
- When the disclosure is for law enforcement purposes. For example, we may disclose PHI about you in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
- When the use and/or disclosure relates to decedents. For example, we may disclose PHI about you to a coroner or medical examiner for the purposes of identifying you should you die.
- When the use and/or disclosure relates to cadaveric organ, eye or tissue donation purposes.
- When the use and/or disclosure relates to medical research.
- When the use and/or disclosure is to avert a serious threat to health or safety.
- When the use and/or disclosure relates to specialized government functions. For example, we may disclose PHI about you if it relates to military or national security activities.
- When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, we may disclose PHI about you to a correctional institution having lawful custody of you.
5. You can object to certain uses and disclosures.
Unless you object, we may use or disclose PHI about you in the following circumstances:
- We may share your name, your room number, and your condition in our patient listing with clergy and with people who ask for you by name. We also may share your religious affiliation with clergy.
- We may share with a family member, relative, friend, or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care. We may share with a family member, personal representative, or other person responsible for your care PHI necessary to notify such individuals of your location, general condition or death.
- We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you, if necessary for the emergency circumstances.
If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call the Health Information Management Department at our hospitals or the CHRISTUS® Trinity Clinic health care provider’s office locations.
6. We may contact you to provide appointment reminders.
We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.
7. We may contact you with information about treatment, services, treatment alternatives, products, or health care providers.
We may use and/or disclose PHI to manage or coordinate your healthcare. This may include telling you about treatments, services, products and/or other healthcare providers.
We may also communicate with you via newsletters, mailings, or other means regarding treatment options, health-related information, disease management programs, wellness programs, or other community-based initiatives or activities in which our facility is participating.
EXAMPLE: If you are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you.
8. We may contact you for fundraising activities.
We may use and/or disclose PHI about you, including disclosure to the CHRISTUS® Trinity Mother Frances Health System Foundation, to contact you for fund raising purposes. The money raised through these activities is used to expand and support the health care services and educational programs we provide to the area. We would only release contact information and the dates you received treatment or services at one of our facilities. If you do not want to be contacted in this way, you must notify us in writing or contact the Privacy Officer listed at the end of this Notice.
** ANY OTHER USE OR DISCLOSURE OF PHI ABOUT YOU REQUIRES YOUR WRITTEN AUTHORIZATION **
Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing. If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures that were being processed before we received your cancellation.
C. You Have Several Rights Regarding PHI About You
1. You have the right to request restrictions on uses and disclosures of PHI about you.
You have the right to request that we restrict the use and disclosure of PHI about you. However, we are not required to agree to your requested restrictions, and even if we agree to your request, in certain situations your restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in section B.4. of this Notice. You may request a Restricted Use of Information form from your nurse or in the Health Information Management Department of any Mother Frances Hospital or any of the Trinity Clinic health care provider locations.
You also have the right to restrict use and disclosure of your medical information about a service or item for which you have paid out of pocket, for payment (i.e. health plans) and operational (but not treatment) purposes, if you have completely paid your bill for this item or service. We will not accept your request for this type of restriction until you have completely paid your bill for this item or service.
2. You have the right to request different ways to communicate with you.
You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number or by email. Your request must be in writing. We must accommodate reasonable requests, but we may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact. You may request alternative communications by submitting the Restricted Use of Information form.
3. You have the right to inspect and receive a copy PHI about you.
You have the right to request to inspect and receive a copy of PHI contained in clinical, billing, and other records used to make decisions about you, but this right does not include psychotherapy notes. Your request must be in writing, and we may charge you related fees. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial. You may request to see and receive a copy of PHI by contacting the Health Information Management department at any of our patient care locations.
4. You have the right to request amendment of PHI about you.
You have the right to request that we make amendments to clinical, billing, and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment. We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to see and copy the record as described in paragraph 3 above. We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment. You may request an amendment of your PHI by contacting the Health Information Management department at any of our patient care locations.
5. You have the right to a listing (accounting) of disclosures we have made.
You have the right to submit a written request for a list of certain of our disclosures of PHI about you for disclosures made up to six (6) years before your request. We are required to provide a listing of all disclosures except those that occurred for the following reasons:
- For your treatment
- For billing and collection of payment for your treatment
- For our health care operations
- Made to or requested by you, or that you authorized
- Occurring as a byproduct of permitted uses and disclosures
- Made to individuals involved in your care, for directory or notification purposes, or for other purposes described in subsection B.5 above
- Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations (please see subsection B.4 above) and
- As part of a limited set of information which does not contain certain information which would identify you
The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information.
If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. You may request a listing of disclosures by submitting your request to the Health Information Management Department in any Mother Frances Hospital or any of the CHRISTUS® Trinity Clinic healthcare provider locations.
6. You have the right to a copy of this Notice.
You have the right to request a paper copy of this Notice at any time by asking in the admissions department of the hospitals, the outpatient clinic services locations, the Trinity Clinic healthcare provider locations, or the Privacy Officer. We will provide a copy of this Notice no later than the date you first receive service from us (except for emergency services, and then we will provide the Notice to you as soon as possible).
D. Special Protections For Highly Confidential Information
Federal and state laws require special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including any portion of your PHI that is: (1) kept in psychotherapy notes; (2) about alcohol and drug abuse prevention, treatment and referral; (3) about HIV/AIDS testing, diagnosis or treatment; or (4) about genetic testing. This information is not disclosed without your authorization except under limited circumstances.
E. You May File A Complaint About Our Privacy Practices
If you think your privacy rights have been violated by any CTMFHS employee or facility, or you want to complain to us about our privacy practices, please contact:
Office of Patient Advocacy
CHRISTUS® Trinity Mother Frances Health System
800 East Dawson
Tyler, Texas 75701
You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. If you file a complaint, we will not take any action against you or change our treatment of you in any way. You have the right to or will receive notifications of breaches of your unsecured protected health information.
F. Effective Date Of This Notice
This Notice of Privacy Practices is effective on September 23, 2013.
For further information contact:
CHRISTUS® Trinity Mother Frances Health System