Wayne Memorial Community Health Centers
601 Park Street, Honesdale, Pennsylvania
Your Information. Your Rights. Our Responsibilities.
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.
You have the right to:
• Get a copy of your paper or electronic medical record
• Request a correction to your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Participate in a health information exchange
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Bill for services and run our organization
• Participate in a Health Information Exchange
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
• Respond to requests from other health care providers involved in your care.
Get an electronic or paper copy of your medical record
• You can ask to get an electronic or paper copy of your medical information that may be used to make decisions about your care. To do so you must complete an Authorization form and present it to the Physicians Office.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. To do so you must contact the Privacy Officer.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests. You may be asked to put your request in writing.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care or payment for services.
• As required by law, if you pay for a service out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. To request this list, contact the Privacy Officer.
• We will include all disclosures except for those about treatment, payment, and health care operations, and those that were made to you or with your authorization.
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action. For example we may ask them to produce documentation validating their legal authority over your health information.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your privacy rights by contacting us using the information on page one.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at: 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/ privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share.
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
There may be a time that you are not able to tell us your preference. For example if you were unconscious. We may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to reduce a serious and imminent threat to health or safety.
• Include your information in an electronic health information exchange (HIE) to be shared with other participating health care professionals.
In these cases we never share your information without your written permission:
• Most sharing of psychotherapy notes.
• Marketing Activities that include payment for / sale of your health information. We may, as long as we do not receive payment from a third party for doing so, give you marketing materials in a face-to-face encounter or tell you about our own health care products and services.
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again. We may also share information to a foundation related to the Center so the foundation may contact you.
Our Uses and Disclosures
How do we typically use or share your health information?
Except for Highly Sensitive Information as referenced below, we typically use or share your health information in the following ways.
• We can use your health information and share it with other professionals who are treating you, such as doctors and nurses.
Example: We may share your health information with another health care provider whom you have been referred to, such as hospital or home health agency.
Run our organization
• We can use and share your health information to run our Centers, improve your care, and contact you when necessary.
Examples: We may review your treatment to evaluate the performance of the staff that cared for you.
We may call and leave a message or mail you a reminder of an appointment. The reminder may include general information such as date and time of the appointment.
Bill for your services
• We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways. Usually this is in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues
• We can share health information about you for certain situations such as:
• Preventing disease
• Reporting of births and deaths
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing serious threats to anyone’s health or safety
Participation in a Health Information Exchange (HIE)
• We may participate in one or more health information exchanges (HIEs) and may electronically share your health information for treatment and permitted health care operations with other participants in the HIE; including entities that may not be listed under “Who Must Comply with this Notice”.
• You have the choice to “opt-out” of HIE participation.
• HIEs allow your health care providers to efficiently access and use your pertinent medical information necessary for treatment. We will not share your information with an HIE unless both the HIE and its participants are subject to HIPAA’s privacy and security requirements.
• For health research when approved by an Institutional Research Review Board.
Comply with the law
• We will share information about you if local, state or federal laws require it; including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
• We can share health information about you with organ procurement organizations to facilitate organ or tissue donation and transplantation.
Work with a medical examiner or funeral director
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• We may share medical information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries and illnesses.
Respond to lawsuits and legal actions
• We can share health information about you in response to a court or administrative order, response to a subpoena or other lawful process.
• We may disclose your health information if asked to do so by a law enforcement official for reasons including (but not limited to) identifying or locating a suspect, witness, victim, missing person or investigating criminal activity.
Health Oversight and Government Agencies
• For the government to monitor the health care systems, government programs and compliance with civil rights laws.
• For special government functions such as military, national security and presidential protective services.
• Some services we provide are performed though contractual relationships with a third party (business associate). We may share your information with them so that they can perform these services on our behalf. All Business Associates sign an Agreement stating that your health information shared will be safeguarded according to national standards.
Treatment alternatives, health related benefits
• We may use your health information to contact you and provide you with information about treatment alternatives or other health related benefits that might be of interest to you.
Sensitive Information: Federal and State laws require additional protection for sensitive medical information in the following categories; drug and alcohol, mental health, HIV/AIDS and Genetic testing.
Generally, you will be asked for a written authorization before this type of information is released. However, there are limited circumstances under the law when this information may be released without your consent.
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Who Must Comply With This Notice?
All of the below entities, sites and locations listed below will follow the terms of this Notice. In addition, the below listed entities, locations and sites may share medical information with each other for treatment, payment and healthcare operations as described in Notice.
• Wayne Memorial Community Health Centers
o All physician, dental and behavioral health offices
o All employees, trainees, students, volunteers and business associates of Wayne Memorial Community Health Centers
Approved by Wayne Memorial Community Health Centers Board of Directors 6/9/2015
(This policy replaces the Notice of Privacy Practices Dated 9/8/2008)