Notice of Privacy Practices

Required by the Health Insurance Portability and Accountablility Act of 1996 (HIPAA)

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.

On the last page of this document is the name and phone number of the Privacy Officer, should you have questions about your privacy rights. You will also find the effective date of this document.

Pikes Peak Regional Hospital is required by law to maintain your privacy and the security of your health information and to provide you with this Notice of Privacy Practices. This Notice describes how your health information may be used and shared, and explains your privacy rights. Pikes Peak Regional Hospital is required to follow the terms of this Notice.

All other uses and disclosures of protected health information not described in this notice will be made only with your written authorization.

WHO WILL FOLLOW THE PRIVACY PRACTICES IN THIS NOTICE – Pikes Peak Regional Hospital provides healthcare to our patients together with physicians and other healthecare professionals. This Notice of Privacy Practices describes how Pikes Peak Regional Hospital will use and disclose medical information as we provide health care. The privacy practices described in this Notice will be followed by:

• Any member of our workforce authorized to enter information into your medical record;
• Members of our medical staff;
• Allied health professionals who participate in your health care;
• All departments and units of Pikes Peak Regional Hospital;
• Any member of our volunteer services.

CHANGES IN THIS NOTICE – Pikes Peak Regional Hospital reserves the right to change our practices and to make the new provisions effective for all protected health information we maintain as well as new information after the change occurs. Should our information practices change, we will change our Notice of Privacy Practices, post the new Notice in our facility and you will receive the new Notice the next time you are admitted or have an outpatient procedure at the hospital.

MEDICAL INFORMATON - Each time you visit a physician, or other provider of health care, a record is made of your visit. This information is used to provide you with quality care and to comply with the law. Your health record is the physical property of the healthcare provider that compiles it; however, the information belongs to you. We are required by law to maintain the privacy of your health information and we are committed to doing so. We will abide by the terms of this notice as required by federal law.

HOW WE USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Treatment – Health information is used to provide you with medical treatment and to coordinate your care. We may share your health information in the provision, coordination or management of health care and related services by one or more health care providers. This includes the coordination and management of health care with a third party, consultation between health care providers, or referrals from one health care provider to another.

Payment – We use and disclose medical information about you in order to determine eligibility for coverage and to collect payment for your medical treatment and services. For example, this could include an insurance company or a third party. If you are covered by health insurance your health plan may need information from us about a surgery or other procedure you received, or will receive, before payment can be made. We may disclose information about you for the payment activities of another healthcare provider if necessary.

Health Care Operations – We will use and share your health information for day-to-day operations necessary to make sure you receive quality care. For example, to assess your satisfaction with our services; remind you of appointments; tell you of possible treatment alternatives; evaluate the treatment you received by our staff; work with oversight organizations which would include audits, investigations, inspections and licensure; assess the care you received and to combine information about you with other patients to determine what additional services should be provided.

Other Healthcare Organizations – We may disclose your health information for the treatment and payment activities of other healthcare providers. For example, a nursing home or home health agency that will provide care for you after discharge.

Future Communications – We may use your health information to mail you information on appointments, health care programs and services, or to raise funds.

Family and Friends – We must disclose your health information to you as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree we do so.

Persons Involved In Care – We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. This includes disaster relief organizations. If you are present we will provide you with the opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment and our experience with common practice to make a reasonable decision in your best interest.

Business Associates – We may disclose your medical information to certain business partners so they may help us do our jobs. To protect your medical information, however, we require the business associate to appropriately safeguard your information as part of a signed agreement.

Hospital Directory – We may include certain limited medical information about you in the hospital directory while you are a patient in the hospital. This information may include your name, location in the facility, general condition and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for regligious affiliation, to other people who ask for you by name. If you do not want your name in the hospital directory, tell the hospital staff at the time you are admitted.

Incidental Use and Disclosure – Your medical information may be disclosed in situations that are incidental to an otherwise permitted use or disclosure. For example, sign-in sheets in physician offices or hospital registration areas may be used; physicians may confer with patients in semi-private rooms; physicians may confer with other health care professionals at the nurses’ stations.

WE MAY SHARE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION IN THE FOLLOWING CIRCUMSTANCES AND WHEN REQUIRED TO DO SO BY FEDERAL OR STATE LAW

Disclosures Required By Law –In response to a valid judicial or administrative order.

Public Health Reporting – We may disclose medical information about you for public health activities that may include the following:

• Prevention or control of disease, injury or disability;
• Reporting spinal cord injuries;
• Reporting head injuries;
• Reporting births and deaths;
• Reporting communicable diseases, including HIV/AIDS, venereal diseases, rabies and animal bites, environmental and chronic diseases, and tuberculosis;
• Notification to people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

Victims of Abuse, Neglect or Domestic Violence –To a government authority authorized to receive reports of abuse, neglect, or domestic violence, including child abuse and elder abuse.

Health Oversight Activities –For oversight activites authorized by law. For example, a Medicare quality improvement organization.

Court Order – In response to an order of a court or administrative tribunal but only the information expressly authorized by the order.

Subpoena or Discovery Request – If we receive satisfactory assurance from the party seeking the information that reasonable efforts have been made to notify you of the request or that reasonable attempts have been made to secure a protective order.

Locate Suspect, Fugitive, Material Witness or Missing Person –To law enforcement officials to locate a suspect, fugitive, material witness or missing person. We may only release name, date and place of birth, social security number, blood type and rh factor, type of injury, date and time of treatment, date and time of death (if applicable), and physical description.

Victims of a Crime – To law enforcement officals regarding the victim of a crime if the victim is incapacitated, but only if law enforcement indicates that the information is needed to determine if a crime has occurred, information is not intended to be used against the victim, and the physician determines that the disclosure is in the victim’s best interest.

Medical Examiners, Coroners, and Funeral Directors – To a coroner, medical examiner, or funeral director, so that they may carry out their job duties, consistent with applicable law.

Organ Procurement –To an organ procurement organization in order to facilitate donation and transplantation of organs, eyes or tissue if you are deceased.

To Prevent Harm – To persons reasonably able to prevent or lessen a serious and imminent threat to the health and safety of an individual or the public, but only under certain circumstances consistent with applicable law.

National Security and Intelligence Activities – To authorized federal officials or military command for military missions or lawful intelligence, counterintelligence or national security activities.

Drug Reactions and Device Failures –To a pharmaceutical or medical device manufacturer to report adverse events and product defects or to individuals about recalls of products they may be using.

Research –To persons associated with research activities, if the organization or entity has received a waiver for receiving authorization by an Institutional Review Board or a privacy board.

Communicable Diseases - To a person who may have been exposed to a communicable disease or is at risk of spreading or contracting a disease if the organization or public health authority is authorized by law to notify the person.

Workplace Surveillance -To an employer if the physician is providing medical surveillance of the workplace or evaluating if an indivdiual has a work-related illness.

Workers' Compensation - To the extent necessary to comply with laws relating to workers’ compensation or other similar programs, established by law, that provide benefits for work-related injuires or illness without regard to fault.

Correctional Institutions and Other Law Enforcement Custodial Situations –To correctional institutions and law enforcement officals having lawful custody or other individuals, provided that the individuals represent that the health information is necessary for the provision of health care, for the safety of the inmate or others, law enforcement at the correctional institution, or safety and security at the institution.

Crime on the Premises –To law enforcement officals to report evidence of a crime on the premises.

Military and Veterans – If you are, or have been, a member of the armed forces, we may disclose information about you as required by military authorities.

PATIENT RIGHTS

You have the following rights with regard to your protected health information. Please contact the privacy officer to obtain the appropriate forms.

Right To Request Restrictions on the Use or Disclosure of Your Health Information – You have the right to request that we not use or share your health information for treatment, payment, or health care operations, or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. Your request must be in writing to the Hospital Privacy Officer, and we will consider your request, but we are not legally required to accept it.

Right to Confidentiality – You may request, in writing to the Hospital Privacy Officer, that your health information be provided in a confidential manner, such as sending mail to an address other than your home. The Hospital will honor reasonable requests.

Right To Inspect and Obtain a Copy of Your Medical Information – You have the right to access and receive copies of your medical information in accordance with Colorado Law C.R.S. 25-1-801 Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and receive copies of the medical information that may be used to make decisions about you, you must submit your request in writing to the Health Information Management department (Medical Records). If you request a copy of your medical information, a fee may be charged for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and receive copies of your medical informaion in certain very limited circumstances. If you are denied access to your medical information, you may contact the Colorado Department of Health in accordance with the procedures provided by Colorado Law C.R.S. 25-1-801, and we will comply with the outcome of the review.

Right To Request that We Correct Your Medical Information – If you feel that the 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 Pikes Peak Regional Hospital. To request an amendment, your request must be in writing and submitted to the Privacy Officer to the address at the end of this notice. 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;
• Is not part of the medical information maintained by us;
• Is not part of the medical information which you would be permitted to review or copy; or
• Is accurate and complete.

Right to a List of Disclosures Made of Your Health Information – You have the right to a list of those instances in which we have shared certain disclosures of health information. We are not required to provide an account of discloures made to carry out treatment, payment and health care operations and in some other specific circumstances. Your request must be in writing to the Hospital Privacy Officer. No disclosures made prior to April 14, 2003 will be provided.

Right to Revoke the Authorization – You have the right to revoke this authorization at any time in writing except (1) to the extent we have already taken action based on your authorization, (2) if it was a condition of obtaining health insurance coverage and the insurer has a right to contest the policy or a claim under the policy, (3) if State or Federal regulations specifically permit the disclosure without your authorization.

Right to a Copy of this Notice - You may ask for a copy of this Notice anytime.

For More Information or to Report a Problem - If you have questions about your privacy rights, would like additional information about something in this Notice, or would like to file a complaint because you believe your privacy rights have been violated, you may contact the Hospital Privacy Officer or the Secretary of the Department of Health and Human Services in Washington, D.C.

All complaints must be submitted in writing.

You will not be penalized or the delivery of healthcare jeopardized for filing a complaint.

PRIVACY OFFICER

If you have questions, requests, or complaints, please contact:

Privacy Officer
16420 West Highway 24
Woodland Park, CO 80863-7707
719-687-9999