Effective Date:  April 14, 2003

MERCY HEALTH SYSTEM OF KANSAS, INC.                    

Corporate office:  401 Woodland Hills Blvd.

Fort Scott, Kansas  66701

NOTICE OF HEALTH INFORMATION 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.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made.  Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.  This information, often referred to as your health or 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 your or a third-party payer can verify that services billed were actually provided

·                    a tool in educating health professionals

·                    a source of data for facility 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 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 to make informed decisions before authorizing disclosure to others.

YOUR HEALTH INFORMATION RIGHTS

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you.  You have the right to:

·                    request a restriction on certain uses and disclosures of your information

·                    obtain a paper copy of the notice of information practices upon request

·                    inspect and obtain a copy of your health record upon written request

·                    obtain an accounting of disclosures of your health information

·                    request communications of your health information by alternative means or at alternative locations

·                    revoke your authorization to use or disclose health information except to the extent that action has already been taken

·                    request an amendment to your health record

OUR RESPONSIBILITIES

This organization is required to:

·                    maintain the privacy of your health information

·                    provide you with a 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

·                    accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain.  If notice is revised a new copy will be offered at your next visit to our facilities.

We will not use or disclose our health information without your authorization, except as described in this notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions and would like additional information, you may contact the Privacy Officer at (620)-223-2200 or (620)-331-2200.

If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer, phone numbers listed above, or with the Secretary of Health and Human Services.  There will be no retaliation for filing a complaint.

EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS

WE WILL USE 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 expectations of the members of your healthcare team.  Members of your healthcare team will then record the actions they took and their observations.  In that way, the physician will know how you are responding to treatment. 

We will also provide your physician or a 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 a third-party payer.  The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

WE WILL USE YOUR HEALTH INFORMATION FOR REGULAR HEALTH OPERATIONS

For example:  Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team 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.

BUSINESS ASSOCIATES

There are some services provided in our organization through contacts with business associates.  Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use 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.

NOTIFICATION

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

COMMUNICATION WITH FAMILY

Health professionals, using their best judgment, may disclose to a family member, other 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.

FUNERAL DIRECTORS, CORONERS, MEDICAL EXAMINERS

We may disclose health information to funeral directors, coroners and medical examiners 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 the procurement, banking, or transplantation of organs for the purpose of tissue donations and transplant.

WORKERS COMPENSATION

We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

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.

CORRECTIONAL INSTITUTION

Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

LAW ENFORCEMENT

We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

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 are engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT BETWEEN HOSPITAL AND MEDICAL STAFF

Mercy Health System of Kansas, Inc.(MHSK),  the independent contractor members of its Medical Staff (including your physician), and other health care providers affiliated with MHSK have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operations.  This enables us to better address your health care needs. 

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer, (620)-223-2200, mail to Privacy Officer, Mercy Health System of Kansas, Inc., 401 Woodland Hills Blvd., Fort Scott, KS.  66701.  Or you may file a complaint with the Secretary of the Department of Health and Human Services.  You will not be penalized for filing a complaint.

 

                                                                                                                                               

Patient Signature                                                                                  Date