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THIS NOTICE DESCRIBES HOW YOUR HEALTH
INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU
CAN ACCESS THIS INFORMATION.
PLEASE REVIEW IT
CAREFULLY. |
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We are required by applicable federal and state law to maintain
the privacy of your health information. We are also required to
give you this Notice about the use and disclosure of your health information
(1), our legal responsibilities (2), and your rights concerning
your health information (3).
We reserve the right to change our privacy practices provided such
changes are permitted by applicable law. Before we make a significant
change in our privacy practices, we will change this Notice and
make a new Notice available upon request. We are required to abide
by the terms of the Notice currently in effect.
You may request a copy of our Notice at any time. For more information
about our privacy practices, or for additional information, contact
our Compliance Liaison at Potawot Health Village.
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1. USE AND DISCLOSURE OF HEALTH INFORMATION |
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We use and disclose health information about you for your treatment,
payment and health care operations. |
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| a. |
For Treatment. We may use
and disclose your health information to a physician or other
health care provider providing treatment to you. We may use
your health information to provide you with appointment reminders
and treatment alternatives. 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. Also, the doctor may
need to send you, and your information, to a specialist to provide
additional care for your broken leg.
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| b. |
For Payment. We may use and
disclose your health information to obtain payment for services
we provide to you. For example, we may need to give your insurance
company information about your clinic visit and the services
you received in order for them to pay us for the service. If
you are an Indian client, we may disclose your information to
the Indian Health Service, who fund services we provide,
or pay for, on behalf of Indian clients. If you are eligible
for Contract Health Services, we may use or disclose your information
when we are paying another provider for services he/she provided
to you.
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| c. |
For Health Care Operations.
We may use and disclose your health information in connection
with our health care operations. Health care operations include
quality assessment and improvement activities, reviewing the
competence or qualifications of health care professionals, evaluating
provider performance, conducting training programs, certification,
licensing or credentialing activities. We may use your health
information to tell you about health related services, educational
activities and program operations that may be of interest to
you. We may use your health information for business management,
general administrative activities and customer service. If you
are an adult Indian client, we may use your name and address
to send you a Voter Information Packet regarding the election
of Indian Community Representatives on the UIHS Board of Directors.
We may disclose statistical and demographic information about
you when seeking grants so we can fund some of our programs.
We will remove information that identifies you so others will
not be able to identify our specific clients. |
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2. LEGAL RESPONSIBILTIES
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We will disclose health information about you when required to
do so by federal, state or local law. These activities generally include
those related to: preventing or controlling disease, injury or disability;
reporting births or deaths, reporting abuse or neglect; reporting
reactions to medications; or to notify people of recalls of products
they may be using. |
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| a. |
Organ and Tissue Donation.
If you are an organ donor, we may release health 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
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| b. |
Military and Veterans. If
you are a member of the armed forces, we may release health
information about you as required by military command authorities.
We may also release health information about foreign military
personnel to the appropriate foreign military authority.
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Workers' Compensation. We
may release health information about you for workers' compensation
or similar programs. These programs provide benefits for work-related
injuries or illness.
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| d. |
Public Health Risks. We may
disclose your information for public health activities such
as assisting public health agencies to prevent or control disease,
injury, or disability.
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Law Enforcement/ Legal Proceedings.
We may disclose health information about you in response to
a subpoena, court or administrative order, to identify or locate
a suspect, fugitive, material witness, or missing person; or
in emergency circumstances to report a crime or determine the
cause of death.
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| f. |
Inmates. If you are an inmate
of a correctional institution or under the custody of a law
enforcement official, we may release health 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.
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National Security
and Intelligence Activities. We may release health information
about you to authorized federal officials as authorized by law.
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Health Oversight Activities. We may disclose health information
to a health oversight agency for activities authorized by law.
For example, these activities might include audits, investigations,
licensure and inspections.
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| i. |
Fundraising. We may use your
information to contact you to raise funds for UIHS. In any fundraising
material we mail to you, we will tell you how to ask to have
your name taken off our mailing list.
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Marketing. We may use your
information to notify you of our new providers or health care
programs or services we provide.
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3. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU. |
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| a. |
Access. You have the right
to look at or get copies of your health information, with limited
exceptions. We ask you make your request in writing. If you
request a copy of the information, the first copy will be provided
at no charge. The second copy we will charge you a reasonable,
cost-based fee for responding to these additional requests.
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| b. |
Amendment. You have the right
to request that we amend your health information. Your request
must be in writing, and it must explain why the information
should be amended. We may deny your request under certain circumstances.
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| c. |
Accounting of Disclosures.
You have the right to receive a list of instances in which we
have disclosed your health information for a purpose, other
than treatment, payment, or healthcare operations. To request
accounting of disclosures, you must submit your request in writing
to Client Records. Your request must state a time period that
may not be longer than six years and may not include dates before
April 14, 2003. If you request this accounting more than once
in a 12-month period, we will charge you a reasonable, cost-based
fee for responding to these additional requests.
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| d. |
Restriction. You have the
right to request a restriction or limitation on the health information
we use or disclose about you for treatment, payment or health
care operations. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except
in an emergency).
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| e. |
Right to Request Confidential
Communications. You have the right to request that we communicate
with you about health matters in a certain way or at a certain
location. You must make this request in writing and it must
specify the alternative means or location that you would like
to receive information about your healthcare.
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Right to Obtain a Paper Copy of
this Notice. You have the right to receive a paper copy
of this notice upon request. Copies will be available at the
registration/reception desks at each clinic site.
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Other uses and disclosures will be made only with your written authorization,
which you may revoke at any time. The revocation must be in writing.
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QUESTIONS AND COMPLAINTS
If you believe your privacy rights have been violated, you may file
a complaint with us, or you may contact the Director of the Office
For Civil Rights, U.S. Department of Health & Human Services,
200 Independence Ave, Room 509F, HHH Bldg., Washington, DC 20201.
To obtain additional information, or to file a complaint with us,
contact the Compliance Liaison at (707) 825-5000.
You will not be penalized for filing a complaint.
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© Copyright 2003 United Indian Health Services. All Rights Reserved. UIHS is a non-profit organization. |
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