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Notice of Privacy Practices
DOWNLOAD THE NOTICE OF PRIVACY PRACTICES (PDF)
EFFECTICE DATE OF THIS NOTICE -- APRIL 14th, 2003.
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.
SAINT MARY’S REGIONAL MEDICAL CENTER
PRIVACY PRACTICES NOTICE
This Notice describes the type of information we gather about you, with whom that information may be shared and the
safeguards we have in place to protect it. You have the right to the confidentiality of your medical information and the
right to approve or refuse the release of specific information except when the release is required by law, or permitted by
law without your authorization.
The provision of this Notice to you is required by the federal "Standards for Privacy of Individually Identifiable Health
Information", 45 CFR Parts 160 and 164 ("the regulations"). The regulations also require that we make a good faith effort
to obtain your written acknowledgement that you have received this Notice. This is why you will be asked to sign this
form.
If the practices described in this Notice meet your expectations, there is nothing you need to do. If you prefer additional
limitations on the use of your medical information, you may request them following the procedure below.
If you have any questions about this Notice, please contact our Privacy Officer.
To contact the Network's Privacy Officer:
Saint Mary's
235 West Sixth Street
Reno, Nevada 89503
Telephone (775) 770-3374
Fax (775) 770-3963
Privacy.Officer@saintmarysreno.com
Who is Saint Mary’s?
Saint Mary's is an organized health care arrangement and a group of affiliated covered entities under the
regulations. The entities involved in Saint Mary's are Saint Mary's Regional Medical Center, The Center
for Outpatient Surgery, Saint Mary’s Eye Institute, Saint Mary’s Outpatient Surgery Center at Galena, Saint Mary’s at
Galena, Family Walk-In Health Center, Nell J. Redfield Neighborhood Health Center, Sun Valley Children’s Clinic, Saint
Mary's Community Health and Wellness, Saint Mary's Home Care Services, Hospice of Northern Nevada, Take Care-AVan,
Mission Services, Saint Mary’s Center for Healthy Hearts, Risk Reduction Center, Executive Physical Program,
TeleHealth, and members of the organized medical staffs of those entities.
Who Will Follow This Notice?
This Notice describes practices of all the persons and entities in the Network regarding the use of your medical
information and that of:
- Any health care professional employed by the Network who is authorized to enter information into your hospital
chart or medical record.
- All departments and units of the Network’s hospitals, clinics or offices you may visit.
- Any member of a volunteer group we allow to help you while you are in the hospital.
- All employees, staff and other personnel who may need access to your information.
- All entities, sites and locations of the Network follow the terms of this notice. In addition, these entities, sites and
locations may share medical information with each other for treatment, payment or health care operations
purposes as described in this Notice.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. Protecting medical information about you
is important. We create a record of the care and services you receive. We need this record to provide you with quality
care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by the
Network, whether made by health care professionals or other personnel.
This Notice will tell you about the ways in which we may 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:
- keep confidential any medical information that concerns your condition or treatment, how your care is paid for
and demographic information, if such information can be used to identify you;
- give you this Notice of our policies, procedures and information privacy practices with respect to medical
information about you; and
- follow the terms of the notice that is currently in effect.
How This Notice Works
This Notice is a "layered notice". What you are reading covers general information, and a summary list of the elements
that are covered in detail in the pages following the space provided for your signature below. Those pages discuss and
summarize the following:
- How other, more stringent Nevada and federal laws on medical information confidentiality will also be observed.
- How we may use and disclose medical information about you for the following purposes: treatment, seeking
payment, operating our entities, providing appointment reminders, informing you of treatment alternatives and
health related benefits and services, communicating with individuals involved in your care, for the hospital
directory, for research, to avert a serious threat to public health and safety, for certain fundraising purposes, and
as required by law.
- A number of special situations where we may use and disclose medical information about you for the following
reasons: as required by military command authorities for members of the armed forces, for worker’s
compensation programs, for organ and tissue donation, in dealing with public health agencies or health oversight
activities authorized by law, in lawsuits and disputes, to law enforcement authorities, coroners, medical
examiners and funeral directors, to protective services for the President of the United States and national
security and intelligence agencies, and if you are an inmate, to correctional authorities.
- Your rights regarding your medical information, including your right to inspect and copy your information, to seek
amendment and correction of your information, to an accounting of certain disclosures of your information we
have made, your right to request additional restrictions (beyond those established by law) on the use and
disclosure of your information, your right to request confidential communications between you and the Network,
and your right to a complete paper copy of this Notice.
- How you can be aware of changes to this Notice that will apply to the use and disclosure of your information.
- How you may complain about our handling of your information.
Nevada Law
In addition to federal law, Nevada law places more stringent limitations on the disclosure and use of mental health
information, genetic information, communicable disease information and blood and urine test results. Other federal
regulations place more stringent requirements on drug and alcohol abuse information. We shall comply with those more
stringent restrictions.
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we may use and disclose medical information. For each category of
uses or disclosures we will try to give some examples. Not every use or disclosure in a category will be listed.
For Treatment. We may use and disclose medical information about you, among members of the Network and to others,
to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses,
technicians, training doctors, or other health care professionals who are involved in taking care of you. For 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. Different health care professionals also may share medical information about you in order to coordinate the
different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about
you to people outside the hospital who may be involved in your medical care after you leave the hospital or that provide
services that are part of your care.
For Payment. We may use and disclose medical information about you, among members of the Network and to others,
so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance
company or a third party. For example, your insurance may need to know about surgery you received so they will pay us
or reimburse you for the surgery. We may also use and disclose medical information about you to obtain prior approval or
to determine whether your insurance will cover the treatment, or to undertake other tasks related to seeking payment for
services provided. We may also disclose medical information to another health care provider who is or has been involved
in your treatment, so that that provider may seek payment for services rendered.
For Health Care Operations Purposes. We may use and disclose medical information about you, among members of
the Network and to others, for health care operations purposes. This is necessary to make sure that all of our patients
receive quality care. 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, or to otherwise manage and operate the Network effectively. We may also
disclose information to doctors, nurses, technicians, training doctors, medical students, and other hospital personnel for
review and learning purposes. We may remove information that identifies you from this set of medical information so
others may use it to study health care and health care delivery without learning the identity of the patient(s).
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.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible
treatment options or alternatives that may be of interest to you.
Health-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.
Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient
at the hospital. This information may include your name, location in the hospital, your general condition (e.g. fair, stable,
etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to
people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or
rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and
generally know how you are doing. If you object to our doing this, please let us know, and we will honor your objection.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a
friend or family member who is involved in your medical care. We may also give information pertinent to payment to
anyone who helps pay for your care. We may also tell your family or friends your condition and that you are in the
hospital. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that
your family can be notified about your condition, status and location.
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
hospital. Otherwise, we may 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 hospital.
As Required By Law. We may 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 health and safety of the public or another person.
Any disclosure, however, would only be to someone able to help prevent the threat.
Fundraising Activities. We may use medical information about you in an effort to raise money for Network entities and
their operations. For example, we may disclose medical information to a foundation related to the hospital so that the
foundation may raise money for the hospital. We would only release contact information, such as your name, address
and phone number. If you do not want the Network to contact your for our fundraising efforts, you must notify our Privacy
Officer in writing at the address provided.
Special Situations
Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that
handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate
organ or tissue donation and transplantation.
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.
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;
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or
domestic violence.
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 overall health care system, the conduct of government programs, and
compliance with civil rights laws.
Lawsuits and Disputes. We may disclose medical information about you in response to a subpoena, discovery request,
or other lawful order from a court.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official as part of law
enforcement activities, in investigations of criminal conduct or of victims of crime, in response to court orders, in
emergency circumstances, or when required to do so by law.
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 of the hospital to funeral directors as necessary to carry out their duties.
Protective Services for the President, National Security and Intelligence Activities. We may release 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, or for intelligence, counterintelligence, and other
national security activities authorized by law.
Inmates. If you are an inmate of a correctional institution or under the lawful 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
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 medical 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 our Health Information Department or Privacy Officer at the address provided. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. In some 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 Network 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 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.
To request an amendment, your request must be made in writing and submitted to our Privacy Officer. 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 “designated record set” kept by the Network;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures."
This is a list of the disclosures we made of medical information about you. This accounting will not include routine
disclosures; including those made to you or pursuant to your authorization, those made for treatment,
payment and operations purposes as discussed above, those made to the facility directory as discussed above,
those made for national security and intelligence purposes and those made to correctional
institutions and law enforcement in compliance with law.
To request this list or accounting of disclosures, you must submit your request in writing to the Health Infomation
Department or our Privacy Officer. Your request must state a time period that may not be longer than 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 cost involved and you may choose to withdraw your request
at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request additional restrictions or limitations 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.
However, 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 our Privacy Officer at the address provided. 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;
and (3) to whom you want the limits to apply.
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 may ask that we only contact you at work or
by mail.
To request confidential communications, you must make your request in writing to our Privacy Officer. 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. If complying with your request entails additional expense over our usual means of communication,
we may ask that you reimburse us for those expenses.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time. Even if you have
agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
To obtain a paper copy of this Notice, please request one in writing from our Privacy Officer at the address provided.
Changes To This Notice
We reserve the right to change our policies and practices concerning the privacy of your medical information and 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 always post a copy of the current Notice near
patient entrances. The Notice will contain the effective date on the first page.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Network or with the Secretary of
the Department of Health and Human Services. To file a complaint with the Network, contact our Privacy Officer at the
phone number or e-mail provided. All complaints must be submitted in writing. You will not be penalized for filing a
complaint.
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, thereafter 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 that we provided to you.
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