| If you have any questions about this notice, please contact
the Facility Privacy Officer by dialing 701-256-6100.
Each time you visit this 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 plan for future care or treatment,
and billing related information. This notice applies to all
the records of your care generated by the hospital whether
made by hospital personnel, agents of the hospital, or your
personal doctor. Your personal doctor may have different
policies or notices regarding the doctor’s use and
disclosure of your medical information created in the doctor’s
office or clinic.
Our Responsibilities
We are required by law to maintain the privacy of your health
information and provide you a description of our privacy
practices. We will abide by the terms of this notice and
notify you if we cannot agree to a requested restriction.
We will accommodate reasonable requests you may have to communicate
health information by alternative means or at alternative
locations.
Use and Disclosures
How we may use and disclose medical information about you.
The following categories describe examples of the way we
use and disclose medical information:
For treatment: We may use medical information about you to
provide you treatment or services. We may disclose medical
information about you to doctors, nurses, technicians, medical
students, or other hospital personnel who are involved in
taking care or you at Cavalier County Memorial Hospital.
For example: a doctor treating you for an injury may need
to know if you have diabetes, because diabetes may slow the
healing process, or if your doctor orders physical therapy,
the nursing staff will need to discuss your care and treatment
with the physical therapist. Different departments of Cavalier
County Memorial Hospital may share medical information about
you in order to coordinate the different things you may need,
such as prescriptions, lab work, meals, and x-rays.
We may 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 are discharged from Cavalier
County Memorial Hospital.
For payment: We may use and disclose medication information
about your treatment and services to bill and collect payment
from you, your insurance company, or a third party payer.
For example: we may need to give your insurance company information
about your surgery so they will pay us or reimburse you for
the treatment. We may also tell you health plan about treatment
you are going to receive to determine whether your plan will
cover it.
For Health Care Operations: Members of the medical staff
and/or quality improvement team may use information in your
health record to assess the care and outcomes in your case
and others like it. The results will then be used to continually
improve the quality of care for all patients we serve. For
example: we may combine medication information about many
patients to evaluate the need for new services, treatment,
or equipment. We may disclose information to doctors, nurses,
and other students for educational purposes.
We may also use and disclose medical information:
- To business associates we have contracted with to perform
the agreed upon service and billing for it;
- To remind you that you have an appointment for medical care;
- To assess your satisfaction with our services;
- To tell you about possible treatment alternatives;
- To tell you about health-related benefits or services;
- To contact you as part of fund raising efforts;
- For population based activities related to improving health
or reducing health care costs;
- For conducting training programs and reviewing competence
of health care professionals.
Business Associates: There
are some services provided in our organization through
contracts with business associates.
Examples may include physician services in the emergency
department and radiology, certain outside laboratories, or
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 for services rendered. To protect
your health information, however, we require the business
associate to appropriately safeguard your information.
Directory: We may include certain limited information about
you in the facility directory while you are here. The information
may include your name, location in the facility, your general
condition (e.g. fair, stable, etc,) and your religious affiliation.
This information may be provided to members of the clergy
and, except for religious affiliation, to other people who
ask for you by name. If you would like to opt out of being
in the facility directory, please request the Opt Out form
from the admission staff or Facility Privacy Officer.
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 or
who helps pay for your care. 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: We may disclose information to researchers when
an institutional review board that has reviewed the research
proposal and established protocols to ensure the privacy
of your health information has approved their research.
Future Communications: We may communicate to you via newsletters,
mail outs, or other means regarding treatment options, health
related information, disease-management programs, wellness
programs, or other community based initiatives or activities
our facility is participating in. You may be contacted by
Cavalier County Memorial Hospital for the purposes of fundraising.
Organized Health Care Arrangement: This facility and its
medical staff members have organized and are presenting you
this document as a joint notice. Information will be shared
as necessary to carry out treatment, payment, and health
care operations. Physicians and caregivers may have access
to protected health information in their offices to assist
in reviewing past treatment as it may affect treatment at
the time.
Affiliated Covered Entity: Protected health information will
be made available to your physician as necessary to carry
out treatment, payment, and health care operations.
As Required by Law:
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 the procurement,
banking, or transplantation of organs for the purpose of
tissue donation and transplant.
Food and Drug Administration (FDA): We may disclose to the
FDA health information relative to adverse events with respect
to food, supplements, product and product defects or post
marketing surveillance information to enable product recalls,
repairs or replacement.
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 workforce 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.
Your Health Information Rights
Although your health record is the physical property of the
healthcare practitioner or facility that compiled it, you
have the 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. We may deny your
request to inspect and copy in certain very limited 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 hospital 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.
- Amend: If you feel that 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 by our facility. We may
deny your request for an amendment and if this occurs, you
will be notified of the reason for the denial.
- An Accounting of Disclosures: You have the right to request
an accounting of disclosures. This is a list of the disclosures
we make of medical information about you.
- Request Restrictions: You have the right to request a restriction
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 payment for your care, like a family member
of friend. For example: you could ask that we not use or
disclose information about a surgery you had. 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.
- Request Confidential Communications: You have the right to
request that we communicate about medical matters in a certain
way or at a certain location. We will agree to the request
to the extent that it is reasonable for us to do so. For
example: you can ask that we use an alternative address for
billing purposes.
- A Paper Copy of This Notice: You have the right to a paper
copy of this notice. You may ask us to give you a 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 exercise any of your rights, please obtain the required
forms from the privacy officer and submit your request in
writing.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised
or changed notice will be effective for information we already
have about you as well as any information we receive in the
future. The current notice will be posted in the hospital
and include the effective date. In addition, each time you
register at or are admitted to Cavalier County Memorial Hospital
for treatment or health care services, we will offer you
a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you
may file a complaint with the hospital by contacting the
main number and asking for the facility privacy officer.
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 use will be made
only with your 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, we will not 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
you.
Karen Backes, Privacy Officer
701-256-6100
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