Notice of Privacy Practices

This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

• Introduction
• Understanding Your Protected Health Information
• Your Health Information Rights
• Our Responsibilities
• For More Information, to Make a Written Request, Report a Problem or File a Complaint
• Examples of Uses and Disclosures for Treatment, Payment and Health Operations
• Uses and Disclosures That Require Your Authorization

Introduction

At Cabell Huntington Hospital we are committed to using and disclosing protected health information about you responsibly. This Notice of Privacy Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective as of April 14, 2003, revised effective June 17, 2013, and applies to all protected health information as defined by federal regulations.

This notice shall apply to the following service delivery locations: Cabell Huntington Hospital, the Hoops Family Children’s Hospital at Cabell Huntington Hospital, and the Edwards Comprehensive Cancer Center, as well as outpatient programs and services offered under the name of Cabell Huntington Hospital on the Hospital campus and at various other locations in West Virginia. Examples of such outpatient programs and services include the Cabell Huntington Hospital Family Medical Centers and Family Urgent Care Center. This notice shall also apply to the Cabell Huntington Hospital Home Health Agency.

This Notice of Privacy Practices covers the employees and volunteers of Cabell Huntington Hospital. In addition, unless they advise you otherwise, this Notice of Privacy Practices shall jointly apply to members of the Cabell Huntington Hospital Medical and Dental Staff and non physician providers, as well as residents and students, but only while they are providing services to you or participating in training programs at Cabell Huntington Hospital, and only as it relates to use and disclosure of your protected health information. Members of the Medical and Dental Staff include those physicians, surgeons, dentists and podiatrists who render medical, dental and podiatric care to you at Cabell Huntington Hospital. Non physician providers include nurse practitioners, certified nurse midwives, physician’s assistants, clinical psychologists and optometrists. Unless otherwise identified as such, members of the Medical and Dental Staff, non physician providers, residents and students are not employees of Cabell Huntington Hospital, and this Notice is not intended to imply that such a relationship exists.

Understanding Your Protected Health Information

Each time you are admitted to Cabell Huntington Hospital, a record of your stay is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This record, often referred to as your "medical record", serves as a:

• Basis for planning your care and treatment,
• Means of communication among the many health professionals who contribute to your care,
• Legal document describing the care you received,
• Means by which you or a third-party payer can verify that services billed were actually provided,
• A tool for educating health professionals,
• A source of data for medical research,
• A source of information for public health officials charged with improving the health of this state and the nation,
• A source of data for our planning and marketing,
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your medical record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your medical record is the physical property of Cabell Huntington Hospital (“the Hospital”), the health information contained in your medical record belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522 (a) by submitting a written request to the Health Information Management Department. The Hospital is not required to agree to a requested restriction except for a disclosure restricted under 45 CFR 522(a)(1)(vi), where you have paid out of pocket in full for healthcare services. In that case, you can request that your health information related to those healthcare services not be shared with your health plan/health insurance company for payment or healthcare operations purposes.
• Request confidential communications of your health information by alternative means or at alternative locations as provided in 45 CFR 164.522 (b) by submitting a written request to the Health Information Management Department;
• Inspect and copy your health information as provided for in 45 CFR 164.524 by submitting a written request to the Health Information Management Department;
• Request an amendment to your health information as provided in 45 CFR 164.526 by submitting a written request to the Health Information Management Department;
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528 by submitting a written request to the Health Information Management Department;
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken by submitting a written revocation to the Health Information Management Department; and
• Obtain a paper copy of this notice of information practices by requesting one at the time you register for services or by taking one from holders located at the registration desk and elsewhere in the Hospital.

Our Responsibilities

Cabell Huntington Hospital is required by law to:

• Maintain the privacy of your health information,
• Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,
• Abide by the terms of this notice,
• Notify you if we are unable to agree to a requested restriction or amendment to your health information,
• Accommodate any reasonable request you may have to communicate health information by alternative means or at alternative locations, and
• Notify you in the event that there is a security breach involving your health information.
• Obtain your prior written authorization before any disclosure of your health information where the disclosure would result in payment to the Hospital other than payment for your care and treatment.

We reserve the right to change our practices and to make the new provision effective for all protected health information we maintain. Should our privacy practices change, we will provide you with a revised notice when you next come to Cabell Huntington Hospital for services. We will discontinue use or disclosure of your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

For More Information, to Make a Written Request, Report a Problem or File a Complaint

If you have any questions about the contents of this notice or would like assistance in filing a written request or to report a problem, please call 304-399-2997 or contact the Cabell Huntington Hospital Privacy Officer, 1340 Hal Greer Boulevard, Huntington WV 25701-0195 or privacyofficer@chhi.org.

If you believe that your privacy rights have been violated, you may file a complaint with Cabell Huntington Hospital by sending a written statement describing the complaint to the Cabell Huntington Hospital Privacy Officer at the address listed above or privacyofficer@chhi.org. If your complaint involves an individual other than an employee or volunteer of Cabell Huntington Hospital, it will be forwarded to the proper representative to handle complaints for that individual, and you will be notified of the name and contact information for that representative. You may also file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either Cabell Huntington Hospital or the Office for Civil Rights.

Examples of Uses and Disclosures for Treatment, Payment and Health Operations

Federal and state laws allow us to use and to disclose your health information in the following ways. We have provided you with one or more examples for each category of use and disclosure, but cannot list every permitted use or disclosure. If you have questions about specific uses or disclosures, please call 304-399-2997 or contact our Privacy Officer at the address listed above.

We will use and disclose your health information for treatment.

For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her directions regarding your care to other members of your healthcare team. Various team members will then implement these directions, recording the actions taken and their observations.

We will also provide your physician or subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from this facility.

We will use your health information for payment.

For example: A bill may be sent to you or to your insurance company that may be responsible for payment for your care. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, medications given and supplies used. However, if you pay your bill out of your own pocket in full, you can request that health information not be shared with your insurance company for purposes of payment or healthcare operations.

We will use your health information for regular healthcare operations.

For example: Members of the medical staff, the risk or performance improvement manager, or members of quality improvement teams may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. We may also contact you by mail or by telephone to ask you questions about your visit to the Hospital as part of our efforts to improve our customer service.

Business associates: There are some services provided in our organization through contacts with business associates. Examples include outside reference laboratories that perform certain laboratory tests, companies that provide billing and collection services, companies that perform patient satisfaction surveys on our behalf, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Directory: Unless you notify us that you object, we will use 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 religious affiliation, to other people who ask for you by name.

Training programs: We participate in a number of training programs for students and residents in a variety of healthcare fields including medicine, nursing, physical therapy, occupational therapy and speech therapy. These students and residents will have access to your health information as part of their training and education, but they are also required to follow the privacy practices set forth in this Notice.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, about your location and general condition.

Communication with family and others: Health professionals, using their best judgment, may disclose to a family member, or relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has received the research proposal and established protocols to ensure the privacy of your health information.

Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in procurement, banking, or transplantation of organs or tissue for the purpose of donation and transplant.

Marketing: We may contact you to provide appointment reminders or information about health screenings, treatment alternatives or other health-related benefits and services that may be of interest to you. However, without your prior written authorization, we will not communicate with you about products or services on behalf of third parties who pay us to make such communications.

Fund raising: In accordance with 45 CFR 164.514(f)(1), we may contact you as part of a fund-raising effort on behalf of the Hospital or the Cabell Huntington Hospital Foundation, Inc. You have the right to opt out of receiving such communications. If you do not wish to receive such communications, please write to our Privacy Officer at the address given above and ask to be removed from any fund raising list.

Food and Drug Administration (FDA): As required by law, we may disclose your health information to the Food and Drug Administration (and other regulatory agencies) with respect to products or activities regulated by such agency. Examples include disclosing your health information in connection with reporting adverse events, product defects or tracking of implantable devices regulated by the FDA.

Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order. In the case of a medical emergency, we may disclose your health information to law enforcement officials if disclosure appears necessary to alert law enforcement to the commission or location of a crime, or the identity of the perpetrator. We may also disclose your health information to a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness or missing person, although we will not disclose information related to your blood typing or DNA. We may also disclose your health information if we believe it is relevant to or constitutes evidence of criminal activity on the premises of Cabell Huntington Hospital.

Threat to health or safety: We may use and disclose your health information if we believe in good faith that the disclosure will prevent or lessen a serious threat of harm to the health or safety of a person or the public. For example, if you have suffered a head injury that makes you unable to safely drive a motor vehicle, we may disclose your relevant health information to the Department of Motor Vehicles.

As required by law: We may use and disclose your health information to the extent that the law requires it. For example, we may have to disclose your health information to Workers’ Compensation or to your employer if you have made a claim for benefits.

If you are incapacitated, incompetent or deceased: If you become incapacitated or incompetent, your health information will be treated in the same way it was treated if you were capable and competent. If an authorization or objection is required, your personal representative or surrogate health care decision maker will be treated in the same manner as you would be treated. If an authorization is required for the release of your health information after your death, the executor or administrator of your estate must sign the authorization.

Organ and tissue donation: If you are an organ or tissue donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation, to assist in organ or tissue donation and transplantation.

News media: Sometimes, the circumstances that brought you to the hospital are of interest to the media. The Hospital uses the terms “good”, “fair”, “serious”, or “critical” to indicate a patient’s condition without sharing specific health information.

Health information involving minors: The health information involving minors will be treated like any other health information, except for the following special rules as provided by West Virginia law:

• Both parents of a child will have equal access to the child’s health information, except as limited by court order or other West Virginia law. The parent objecting to a release of health information to the other parent has the duty to provide the Hospital with a court order prohibiting the release of such information.
• Health information and records of the diagnosis, treatment or counseling of a minor for drug or alcohol abuse or addiction will not be released to the parents or guardians without the minor’s consent.
• Health information and records of the diagnosis, treatment or testing of a minor for a sexually transmitted disease will not be released to a parent or guardian without the minor’s consent.
• Health information involving any prenatal care rendered to a minor, or the use of birth control by a minor, will not be released to a parent or guardian without the minor’s consent.

Additional disclosures: Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Uses and Disclosures That Require Your Authorization

Except as otherwise authorized by law, all other uses and disclosures of your health information, including uses and disclosures not described in this Notice, will be made only with your written authorization. You may revoke your authorization at any time pursuant to 45 CFR 164.508(b)(5) by writing down your revocation and sending it to: