NOTICE OF PRIVACY PRACTICES
Effective: March 19, 2012
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This Facility is required by law to provide you with this Notice so that you will understand how we may use or share your information from your Designated Record Set. The Designated Record Set includes financial and health information referred to in this Notice as “Protected Health Information” (“PHI”) or simply “health information.” We are required by law to maintain the privacy of your health information, to provide you with notice of our legal duties and privacy practices with respect to your health information, to abide by the terms of this Notice, and to notify you following a breach of your unsecured health information. We will not use or give to others your health information without your written permission, except as stated in this Notice. If you have any questions about this Notice, please contact Health Information Management at 303-688-2500 x 109.
UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION
Each time you are admitted to our Facility, a record of your stay is made containing health and financial information. Typically, this record contains information about your condition, the treatment we provide and payment for the treatment. We may use and/or disclose this information to:
Understanding what is in your record and how your health information is used helps you to:
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
The following categories describe the ways that we use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall into one of the categories.
OTHER ALLOWABLE USES OF YOUR HEALTH INFORMATION
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health 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 to you.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Although your health record is the property of the Facility, the information belongs to you. You have the following rights regarding your health information:
You must submit your request in writing to our Health Information Director/Privacy Officer. We may charge a fee for the costs of copying, mailing or other supplies associated with your request.
You must submit your request in writing to Health Information Director/Privacy Officer. In addition, you must provide a reason for your request.
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:
You must submit your request in writing to our Health Information Director/Privacy Officer. Your request must state a time period which may not be longer than six years from the date the request is submitted and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve month period will be free. For additional lists, we may charge you for the costs of providing the list. 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.
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.
You must submit your request in writing to our Health Information Director/Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
You must submit your request in writing to our Health Information Director/Privacy Officer. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
To obtain a paper copy of this Notice, contact our Health Information Director/Privacy Officer.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the Facility and on the website. The Notice will specify the effective date on the first page. In addition, if material changes are made to this Notice, the Notice will contain an effective date for the revisions and copies can be obtained by contacting the Facility administrator.
If you believe your privacy rights have been violated, you may file a complaint with the Facility or with the Secretary of the Department of Health and Human Services. To file a complaint with the Facility or to obtain further information about matters covered by this Notice, contact our Health Information Director/Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Brookside Inn Notice of Privacy Practices
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