Pomegranate Health Systems, Inc
Effective Date: September 2005
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.
If you have any questions about this notice, please contact:
Pomegranate Health Systems, Inc
WHO WILL FOLLOW THIS NOTICE
This notice describes our practice and that of:
- Any health care professional authorized to enter information into your office chart;
- All departments and units of the office practice;
- All members of a volunteer group we allow to help you while you are in the office;
- Any medical student, intern, resident, or fellow that we allow to help you while you are in the office;
- Any representative of an insurance carrier, managed care organization, clinical research organization, data analysis organization, or quality improvement organization that is participating in a review of your medical care;
- All employees, staff and other office personnel; and,
- All other entities, sites, and locations where the health care professional in this office practice and follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or operations purposes as described in this notice
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 care and services you receive at this office. We need this record to provide you with quality care and to comply with certain legal requirements. This office applies to all the records of your care generated by the office, whether made by office personnel or your personal doctor.
This notice will tell you about the ways in which we 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;
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Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
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Follow the terms of the notice that is currently in effect.
HOW WE 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 use or disclosure we will explain what we mean and try to give 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.
Treatment - We will use and disclose your health information without your authorization to provide your health care and any related services. We will also use and disclose your health information to coordinate and manage your health care and related services. For example, we may need to disclose information to a case manager who is responsible for coordinating your care. We may also disclose your health information among our clinicians and other staff (including clinicians other than your therapist or principal clinician), who work at our agency. For example our staff may discuss your care at a case conference. In addition, we may disclose your health information without your authorization to another health care provider (e.g., your primary care physician or a laboratory) working outside of Pomegranate Health Systems, Inc. for the purpose of your treatment. Different departments of the office also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
Payment - We may use and disclose your health information without your authorization so that the treatment and services you receive are billed to, and payment is collected from, your health plan or other third party payer. By way of example, we may disclose your health information to permit your health plan to take certain actions before your health plan approves or pays for your services. These actions may include:
- Making a determination of eligibility of coverage for health insurance;
- Reviewing your services to determine if they were medically necessary;
- Reviewing your services to determine if they were appropriately authorized or certified in advance of your care; or,
- Reviewing your services for purposes of utilization review, to ensure the appropriateness of your care, or to justify the changes for your care.
For example, your health plan may ask us to share your health information in order to determine if the plan will approve additional visits to your therapist. We may also disclose your health information to another health care provider so that provider can bill you for services they provided to you, for example an ambulance service that transported you to the hospital.
Health Care Operations -We may use and disclose medical information about you to office operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. These activities include, by way of example, quality assessment and improvement, reviewing the performance or qualifications of our clinicians, training students in clinical activities, licensing, accreditation, business planning and development and general administrative activities. 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. We may also combine medical information about many office patients to decide what additional services that office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes. We may also combine the medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services that we offer.
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 office.
Treatment Alternatives -We may use and disclose medical information to tell you about or recommend possible treatment options and alternatives that may be of interest to you.
Heath-Related Benefits and Services -We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Facility Directory - We maintain a limited facility directory within our residential treatment facility for the purpose of allowing visitors and callers to locate you and to allow clergy to determine your religious affiliation. This limited information will only be provided to individuals who ask for you by name and may include your name, location of facility, your general condition, and your religious affiliation. A statement of your general condition may, for example, state that you are stable or inform a caller of your visitation and telephone privileges, but will not disclose the diagnosis or type of treatment you are receiving. When you are admitted to our residential facility, you will generally have an opportunity to object to be included in our facility directory. If you choose NOT to be included in the facility directory, your directory information will not be provided to the clergy or to a person asking for you by name. Nor will you be identified as present on the unit.
If you are admitted in an emergency room, the clinician responsible for you admission will determine if, in his/her professional judgment, you are capable of agreeing or objecting to being identified in the facility directory. If the clinician determines that you are not able to agree or object (e.g., you are not conscious or able to communicate clearly), that clinician will decide if it is in your best interest, you will be listed in our facility directory. If you later become able to make your own health care decisions, we will ask whether you agree or object to being listed in our facility directory and we will honor your expressed wishes at the time.
WE DO NOT MAINTAIN A FACILITY DIRECTORY AT ANY OF OUR OUT- PATIENT CLINICS. If asked, we will not confirm orally, in writing or through any other medium that you are our current or former client, with the exceptions listed below under "Individuals Involved in Your Care or Payment of Your Care."
Individuals Involved in Your Care or Payment of Your Care -We may release medical information about you to someone who helps pay for your care. We may use or disclose your health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. We may also use or disclose your health information to an entity assisting in disaster relief efforts and to coordinate uses and disclosures for this purpose to family or other individuals involved in your heath care. In limited circumstances, we may disclose health information about you to a friend or family member who is involved in your care. If you are physically present and have the capacity to make health care decisions, your health information may be disclosed with your agreement to persons you designate to be involved in your care. But if you are in an emergency situation but are unable to make health care decisions, we will disclose your health information to:
- A person designated to participate in your care in accordance with an advance directive validly executed under state law,
- Your guardian or other fiduciary if one has been appointed by a court, or
- If applicable, the state agency responsible for consenting to your care.
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 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, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the office. We will almost always 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 office.
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 safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
SPECIAL SITUATIONS
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.
If you are a member of the Armed Forces, we may disclose medical information about you to the Department of Veterans Affairs upon your separation or discharge from military services. This disclosure is necessary for the Department of Veterans Affairs to determine whether you are eligible for certain benefits.
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.
Public Health Risks -We may disclose medical information about you for public health activities. These activities generally include the following:
- To prevent or control disease, injury or disability;
- To report births and deaths;
- To report child 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; and,
- To notify the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities -We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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.
Lawsuits and Disputes - If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
WE WILL NOT provide information in response to a subpoena without your authorization if the request is for records of a federally-assisted substance abuse program.
Law Enforcement -We may release medical information if asked to do so by a law-enforcement official:
- In response to a court order, subpoena, warrant, summons, or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- 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 office or ambulatory surgery center; 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 a coroner or medical examiner. 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 to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities - We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others - We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Department of State - We may use medical information about you to make decisions regarding your medical suitability for a security clearance or service abroad. We may also release your medical suitability determination to the officials in the Department of State who need access to that information for these purposes.
Inmates - 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 law enforcement official. This release would be necessary (1) for the institution to provide you with health care, (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Use and disclosures not described about will generally only be made with your written permission, called and "authorization." You have the right to revoke an authorization at any time. If you revoke your authorization we will not make any further uses or disclosures of health information under that authorization, unless we have already taken an action relying upon the uses or disclosures you have previously authorized.
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 medial information that may be used to make decisions about your care. 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, you must submit your request in writing to Pomegranate Health Systems, Inc.
If you request a copy of the information, we may charge a fee as permitted by state law for the costs of copying, mailing or other supplies associated with you 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 health care professional chosen by the office 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 - If you feel that medical information we have about you is incorrect or incomplete, 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 office.
To request and amendment, your request must be made in writing and submitted to Pomegranate Health Systems, Inc. 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 office;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
If we deny your request to amend, we will send you a written notice of the denial stating the basis for the denial and offering you the opportunity to provide a written statement disagreeing with a denial. If you do not wish to prepare a written statement of disagreement, you may ask that the requested amendment and our denial be attached to all future disclosures of the health information that is the subject of your request. If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal to your statement of disagreement. In this case, we will attach the written request and the rebuttal (as well as the original request and denial) to all future disclosures of the health information that is the subject of your request.
Right to an Accounting of Disclosures - You have the right to request an "accounting of disclosures." This is a list of disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to Pomegranate Health Systems, Inc. Your request must state a time-period that may not be longer that 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, electronically). 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 costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
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 health care 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 that you had. We are not required to agree to 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 Pomegranate Health Systems, Inc. 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; (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 by mail.
To request confidential communications, you must make your request in writing to Pomegranate Health Systems, Inc.; 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 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.
CHANGE 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 the office. 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 seen at the office for treatment or health care services as an outpatient, we will offer you a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services. To file a complaint with the office, contact Pomegranate Health Systems, Inc. at 800-476-1363. All complaints must be submitted in writing.
WHO WILL FOLLOW THIS NOTICE
Pomegranate Health Systems, Inc. will follow this notice of Privacy Practices.
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 we provided to you.
