Your Information. Your Rights. Our Responsibilities. This notice of privacy practices 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 . . .
- Request a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Request a list with whom we’ve shared your information
- Request a copy of this privacy notice
- Choose someone to act for you
- 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
- Include you in a hospital directory
- Provide mental healthcare
- Market our services and sell your information
- Raise funds
We may use and share your information as we . . .
- Treat you
- Run our organization
- Bill for your services
- 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 law suits and legal actions.
Audubon County Memorial Hospital and Clinics (“Hospital”) is required by the Health Insurance Portability and Accountability Act of 1996, and the Health Information Technology for Economic and Clinical Health Act (found in Title XIII of the American Recovery and Reinvestment Act of 2009) (collectively referred to as “HIPAA”), as amended from time to time, to maintain the privacy of individually identifiable patient health information (this information is “protected health information” and is referred to herein as “PHI”). We will only use or disclose your PHI as permitted or required by applicable laws and regulations.
Audubon County Memorial Hospital and Clinics understands that your health information is highly personal, and we are committed to safeguarding your privacy. It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your health information. This Notice of Privacy Practices (“Notice”) is intended to provide you with this information. Please read this Notice of Privacy Practices thoroughly. It describes how we will use and disclose your PHI. This Notice applies to the delivery of health care by Audubon County Memorial Hospital and Clinics and its medical staff in the main hospital, outpatient departments and clinics. This Notice also applies to the utilization review and quality assessment activities of Hospital.
AUDUBON COUNTY MEMORIAL HOSPITAL AND CLINICS’ RESPONSIBILITIES
Audubon County Memorial Hospital and Clinics is required to:
- Maintain the privacy and security of your protected health information;
- Provide you with a notice of the legal duties and privacy practices regarding health information collected and maintained about you;
- Follow the duties and privacy practices described in this notice and give you a copy of it; and
- Notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
We reserve the right to make changes to this Notice. We reserve the right to make the revised or changed Notice provisions effective for all health information we already have about you as well as any information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. We will post a copy of the current Notice in Audubon County Memorial Hospital and Clinics, and each version of the Notice will have an effective date. If the Notice has been modified since you were last seen at Audubon County Memorial Hospital and Clinics, we will offer you a copy of the current Notice in effect.
YOUR HEALTH INFORMATION RIGHTS
This section describes your rights regarding the health information Audubon County Memorial Hospital and Clinics maintains about you.
Right to Request Restrictions: You have the right to request restrictions on how your health information is used or disclosed for treatment, payment, or health care operations activities. We are not required to agree to your requested restriction, unless that restriction is regarding disclosure of health information to your health insurance company and: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (2) the health information pertains solely to a health care item or service for which you or another person (other than your health insurance company) paid for in full. If we agree to your requested restriction, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must provide written request to Audubon County Memorial Hospital and Clinics.
Right to Receive Confidential Communications: You have the right to request that Audubon County Memorial Hospital and Clinics communicate your health information to you by alternative means or at alternative locations. Audubon County Memorial Hospital and Clinics shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record. To request confidential communications, you must make your request in writing to Audubon County Memorial Hospital and Clinics.
Right to Inspect and Copy: You have the right to inspect and obtain a copy of your medical records and your billing information. This right may not apply to psychotherapy notes and certain other information. Audubon County Memorial Hospital and Clinics may charge you a cost-based fee for the labor, supplies, and postage required to meet your request.
You may request access to your health information in a certain electronic form and format, if readily producible, or, if not readily producible, in a mutually agreeable electronic form and format. Further, you may request in writing that we transmit such a copy to any person or entity you designate. Your written, signed request must clearly identify such designated person or entity where you would like us to send the copy.
This request for access to your health care record must be made to the Health Information Department. We may deny your request to inspect and copy in certain very limited circumstances. For example, you do not have the right to psychotherapy notes or to inspect the information which is subject to law prohibiting access. If you are denied access to your health information, you may request that the denial be reviewed by a licensed health care professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
You will be charged a reasonable copying fee in accordance with applicable federal or state law.
Right to Amend: You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. To request an amendment, you must make your request for amendment to your PHI in writing to Audubon County Memorial Hospital and Clinics, including your reason to support the requested amendment.
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 Audubon County Memorial Hospital and Clinics, 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 or is not part of the medical information kept by or for Audubon County Memorial Hospital and Clinics;
- Is not part of the information which you would be permitted to inspect and copy (due to condition or nature); or
- Is accurate and complete;
If your request is denied, we will provide you with information about our denial and how you can file a written statement of disagreement with us that will become part of your medical record. You may ask that Audubon County Memorial Hospital and Clinics include your request for amendment and the denial any time that Audubon County Memorial Hospital and Clinics subsequently discloses the information that you wanted changed. Audubon County Memorial Hospital and Clinics may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.
Right to Accounting of Disclosures: You have the right to an accounting of disclosures of your health information that Audubon County Memorial Hospital and Clinics has made. Please note that certain disclosures need not be included in the accounting we provide to you. The accounting will describe the dates of each disclosure, the name of the entity or person who received the information and, if known, the address of the entity or person, a brief description of information disclosed, and the reason for disclosure. The accounting will not include the following disclosures:
- To carry out treatment, payment or health care operations;
- To you;
- To persons involved in your care;
- For national security or intelligence purposes; or
- To correctional institutions or law enforcement officials.
To request this list, you must make your request for an accounting of disclosures in writing to Audubon County Memorial Hospital and Clinics. Your request must state a time period that may not go back further than six years. The first list you request within a 12-month period will be provided free of charge. For additional lists in a 12-month period, we may charge you a reasonable cost-based fee for providing the additional accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice at any time upon request, even if you previously agreed to receive this Notice electronically. You may obtain a copy of this Notice at our website at acmhhosp.org.
USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
The following categories describe the ways that Audubon County Memorial Hospital and Clinics may use and disclose your health information without your written authorization.
Treatment: Audubon County Memorial Hospital and Clinics may use or disclose health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at Audubon County Memorial Hospital and Clinics. For example, your health information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
Payment: Audubon County Memorial Hospital and Clinics may use or disclose health information about you to send bills and to collect payment from you, your insurance company, or other third-party payers, for the treatment and other services you may receive during the course of patient care. For example, we may need to give your health insurer information about surgery you received at Audubon County Memorial Hospital and Clinics so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. The bill may include information that identifies you, your diagnosis, and your treatment.
Healthcare Operations: Audubon County Memorial Hospital and Clinics may use or disclose your health information to conduct certain of our business activities, which are called health care operations. These uses and disclosures are necessary to provide quality care to all Hospital patients and to facilitate the functioning of Audubon County Memorial Hospital and Clinics. For example, we may use your health information for quality assessment and improvement activities, case management, necessary credentialing, and for other essential activities. We may also combine the health information about many patients to determine where we can make improvements in the care and services we offer. We may also disclose your health information to third party “business associates” that perform various services on our behalf, such as transcription, billing, and collection services. In these cases, we will enter into a written agreement with the business associate to ensure they protect the privacy of your health information.
Patient Directory: We may include certain limited information about you in Audubon County Memorial Hospital and Clinics directory while you are a patient at Audubon County Memorial Hospital and Clinics. This information may include your name, location in Audubon County Memorial Hospital and Clinics, 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 do not ask for you by name. You have the right to request that your name not be included in the directory. If you request to opt-out of the facility directory, we cannot inform visitors of your presence, location, or general condition. If you do not want to be listed in the directory or for your information to be given out, you must notify the Privacy Officer in writing.
Persons Involved in Your Care or Payment of Your Care: If you verbally agree to the use or disclosure and in certain other situations, we will make the following uses and disclosures of your health information. We may disclose to your family, friends, and anyone else whom you identify who is involved in your medical care or who helps pay for your care, health information relevant to that person’s involvement in your care or paying for your care. We may use or disclose your health information to notify or assist in notifying a family member or any other person responsible for your care regarding your physical location, general condition, or death. You have a right to request that your PHI not be shared with some or all of your family or friends.
Spiritual Care: Directory information, including your religious affiliation, will be given to a member of the clergy, even if they do not ask for you by name. Spiritual care providers are members of the health care team at Audubon County Memorial Hospital and Clinics and may be consulted upon regarding your care. You have the right to request that your name not be given to any member of the clergy.
Media Reports: Audubon County Memorial Hospital and Clinics will release facility directory information to the media (excluding religious affiliation) if the media requests information about you using your name and after we have given you an opportunity to agree or object.
As Required by Law: We may use or disclose your health information when required by law to do so. Examples include disclosures in response to a court order / subpoena, mandatory state reporting (e.g., gunshot wounds, victims of child abuse or neglect), or information necessary to comply with other laws such as workers’ compensation or similar laws. Audubon County Memorial Hospital and Clinics will report drug diversion and information related to fraudulent prescription activity to law enforcement and regulatory agencies.
Public Health Reporting: We may disclose your health information to public health agencies as authorized by law, including:
- To prevent or control disease, injury or disability, to report births and deaths, and for public health surveillance, investigations, or interventions;
- To report child abuse or neglect;
- For activities related to the quality, safety or effectiveness of FDA-regulated products;
- To notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition as authorized by law; and
- To notify an employer of findings concerning work-related illness or injury or general medical surveillance that the employer needs to comply with the law if you are provided notice of such disclosure.
Reporting Victims of Abuse, Neglect, or Domestic Violence: Audubon County Memorial Hospital and Clinics may disclose health information if we reasonably believe that you have been the 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: Audubon County Memorial Hospital and Clinics may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
Judicial and Administrative Proceedings: Audubon County Memorial Hospital and Clinics may disclose your health information pursuant to a court order if you are involved in a legal proceeding. Under most circumstances when the request is made through a subpoena, a discovery request, or involves another type of administrative order, your authorization will be obtained before disclosure is permitted.
Law Enforcement: HIPAA allows Audubon County Memorial Hospital and Clinics to disclose your health information, within limitations, to a law enforcement official in the following circumstances:
- 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 the victim agrees or we are unable to obtain the victim’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at Audubon County Memorial Hospital and Clinics; and
- In an emergency situation, to report a crime, the location of the crime or victim, or the identity, description, or location of the person who committed the crime.
However, Iowa law may require a court order for the release of confidential medical information in these circumstances. Accordingly, under some limited circumstances we will request your authorization prior to permitting disclosure.
Coroners and Medical Examiners: Audubon County Memorial Hospital and Clinics may disclose health information to a coroner or medical examiner to identify a deceased person or determine the cause of death.
Funeral Directors: Audubon County Memorial Hospital and Clinics may disclose health information to funeral directors consistent with applicable law, and as necessary to carry out their duties with respect to a deceased person.
Organ and Tissue Donation: We may disclose your 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.
Research: Under certain circumstances, Audubon County Memorial Hospital and Clinics may use or disclose your health information for research purposes. For example, a research project may involve comparing the efficacy of one medication over another. For certain research activities, an Institutional Review Board (IRB) or Privacy Board may approve uses and disclosures of your health information without your authorization. Audubon County Memorial Hospital and Clinics will obtain your written authorization to use or disclose your PHI for research purposes when required by HIPAA.
To Avert Serious Threat to Health or Safety: If there is a serious threat to your health and safety or the health and safety of the public or another person, Audubon County Memorial Hospital and Clinics may disclose your protected health information in a very limited manner to someone able to help prevent the threat.
Disclosures for Specialized Government Functions: In certain circumstances, HIPAA authorizes Audubon County Memorial Hospital and Clinics to use or disclose your health information to authorized federal officials for the conduct of national security activities and other specialized government functions. Audubon County Memorial Hospital and Clinics will use or disclose PHI to the Department of Veterans Affairs to determine where you are eligible for certain benefits.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official to assist them in providing you with health care, protecting your health and safety or the health and safety of others, or for the safety and security of the correctional institution
Workers’ Compensation: Audubon County Memorial Hospital and Clinics may disclose your health information as necessary to comply with laws related to workers’ compensation or similar programs. Please be aware that Iowa and other federal laws may have additional requirements that we must follow, or may be more restrictive than HIPAA on how we use and disclose your health information. If there are specific more restrictive requirements, even for some of the purposes listed above, we may not disclose your health information without your written permission as required by such laws. For example, we will not disclose your HIV test results without obtaining your written permission, except as permitted by Iowa law. We may also be required by law to obtain your written permission to use and disclose your information related to treatment for a mental illness, developmental disability, or alcohol or drug abuse.
OTHER USES AND DISCLOSURES
Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. Some examples include:
Psychotherapy Notes: We usually do not maintain psychotherapy notes about you. If we do, we will not use and disclose your psychotherapy notes without your written authorization except as otherwise permitted by law.
Marketing: Subject to certain limited exceptions, your written authorization is required in cases where Audubon County Memorial Hospital and Clinics receives any direct or indirect financial remuneration in exchange for making the communication to you which encourages you to purchase a product or service or for a disclosure to a third party who wants to market their products or services to you.
Sale of Your Health Information: Subject to certain limited exceptions, we will not sell your health information without your written authorization except as otherwise permitted by law.
Any other uses or disclosures of PHI that are not described in this Notice of Privacy Practices require your written authorization. Written authorizations will let you know why we are using your PHI. You have the right to revoke an authorization at any time.
If you authorize Audubon County Memorial Hospital and Clinics to use or disclose your health information, you may revoke that authorization, in writing, at any time. However, your decision to revoke the authorization will not affect or undo any use or disclosure of your health information that occurred before you notified us of your decision, or any actions that we have taken based upon your authorization. If you revoke an authorization that was obtained as a condition of obtaining insurance coverage, other law still allows the insurance company to contest a claim under the policy.
More Stringent State and Federal Laws: The State law of Iowa is more stringent than HIPAA in several areas. Certain federal laws also are more stringent than HIPAA. Hospital will continue to abide by these more stringent state and federal laws. The federal laws include applicable internet privacy laws, such as the Children’s Online Privacy Protection Act and the federal laws and regulations governing the confidentiality of health information regarding substance abuse treatment. The State of Iowa is more stringent when the individual is entitled to greater access to records than under HIPAA. State law also is more restrictive when the records are more protected from disclosure by state law than under HIPAA. In cases where Hospital provides treatment to a patient who resides in a neighboring state, Hospital will abide by the more stringent applicable state law.
SHARING AND JOINT USE OF YOUR HEALTH INFORMATION
In the course of providing care to you and in furtherance of Audubon County Memorial Hospital and Clinics’ mission to provide excellence with quality and compassion to those we serve, Audubon County Memorial Hospital and Clinics will share your PHI with other organizations as described below who have agreed to abide by the terms described below:
Quality Assessment and Peer Review Functions: Methodist Jennie Edmundson Hospital (MJE) participates with Audubon County Memorial Hospital and Clinics in an organized health care arrangement for utilization review and quality assessment activities. We have agreed to abide by the terms of this Notice with respect to PHI created or received as part of utilization review and quality assessment activities of MJE and its affiliate members. Members of MJE will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or healthcare operations. MJE and this organization may share your PHI for utilization review and quality assessment activities.
Business Associates: Hospital will share your PHI with business associates and their Subcontractors contracted to perform business functions on Audubon County Memorial Hospital and Clinics behalf.
We may use your demographic information (such as name, contact information, age, gender, and date of birth), the dates you received services from us, the department of your service, your treating physician, outcome information, and health insurance status to contact you in an effort to raise money for Audubon County Memorial Hospital and Clinics and its operations. We may disclose health information to a foundation related to Audubon County Memorial Hospital and Clinics so that the foundation may contact you in raising money for Audubon County Memorial Hospital and Clinics. You have the right to opt out of receiving fundraising communications.
If you believe your privacy rights have been violated, you may file a complaint with Audubon County Memorial Hospital and Clinics or with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. To file a complaint with Audubon County Memorial Hospital and Clinics, contact Melanie Larsen, Privacy Officer, at (712) 563-5238 or firstname.lastname@example.org. You will not be retaliated against for filing a complaint.
If you have any questions, concerns, or want further information regarding the issues covered by this Notice of Privacy Practice or seek additional information regarding Audubon County Memorial Hospital and Clinics’ privacy policies and procedures, please contact:
Director of Performance Improvement / Infection Control / Compliance Officer
Audubon County Memorial Hospital and Clinics
515 Pacific Avenue
Audubon, IA 50025
This Notice of Privacy Practices version is effective July 1, 2020, which supersedes all previous versions. We reserve the right to change the terms of this notice, and to make the new Notice provisions effective for all PHI that it maintains. The new Notice will be available upon request and on our web site. We will distribute / provide you with a revised Notice at your first visit following the revision of the Notice in cases where we make a material change in the Notice. You can also ask us for a current copy of their Notice at any time.