Methodist Health System Privacy Notice

MHS Privacy Notice (Spanish version)

NEBRASKA METHODIST HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES

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 Notice applies to the following organizations that are affiliated as part of the Methodist Health System ("MHS") and share similar information practices:
•    Methodist Health System (402) 354-2174
•    Nebraska Methodist Hospital and Methodist Women’s Hospital (402) 354-4667
•    Jennie Edmundson Hospital (712) 396-6084
•    Physicians Clinic, Inc. (402) 354-5616
•    Heart Consultants, P.C. (402) 354-4667
•    Methodist Endoscopy Center, LLC (402) 354-4667

The organizations listed above will share your health information with each other, as necessary, to carry out treatment, payment and health care operations.

Understanding Your Health Record/Information
Every time you visit a hospital, physician or other health care provider, a record of your visit is made. This record may include your symptoms, examination and test results, diagnosis, treatment and plans for future care or treatment. Your medical provider uses this information — your health record — to plan your care and treatment. The many health care professionals who assist in your care communicate through your health record.  Your health information is also used by insurance companies to verify that services for which we billed were actually provided.

Your Rights
Although your health record belongs to the health care provider or facility that compiled it, you do have certain rights with regard to your health information.
•    You have a right to expect that your health information will be kept secure and used only for legitimate purposes.
•    You have a right to understand how your health information may be used and disclosed by MHS affiliates.
•    You have a right to receive this privacy notice that tells you how your health information may be used or disclosed.
•    You have a right to ask questions about any health privacy issue and have those questions clearly and promptly answered.
•    You have a right to know who has received your health information during the previous 6 years, and for what purpose. If you make additional requests for such an accounting during any 12-month period, we may charge you a reasonable, cost-based fee.
•    You have a right to view, and to keep a copy, of all of your health records (except psychotherapy notes). Your request for a copy of your record must be in writing.  If we provide an electronic copy of your record, we may charge a reasonable, cost-based, copying or labor fee.
•    You have a right to ask for correction of anything in your records that you feel is in error.  You also have the right to request that a statement of disagreement be included in your record.  Your request must be in writing and include supporting documentation.
•    You have a right to authorize or refuse additional uses of your health information, such as for fundraising, marketing or research.
•    You have a right to request extra protections for health information you consider especially sensitive, and to request that we communicate with you by alternative means.  However, we are not required to accommodate your request except as provided below.
•    You have the right to be notified of a breach of your unsecured protected health information.

Our Responsibilities
We also have certain responsibilities. These include:
•    Maintaining the privacy of your health record;
•    Providing you with a copy of this Notice;
•    Abiding by the terms of this Notice;
•    Notifying you if we are unable to agree to a requested amendment or restriction; and
•    Accommodating reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We may revise this Notice as our information practices change.  Any revision will be effective for all information in the record, regardless of whether it was gathered before or after the change took effect. However, before we change our practices, a copy of our new notice will be posted at all Methodist Health System affiliates and on our Web site. The effective date of our Notice will always appear at the end of the Notice.

We will not use or disclose, except in limited circumstances that include treatment and the training of staff, psychotheraphy notes pertaining to you without your authorization.
We will not use or disclose your health information for marketing purposes without your authorization.
We will not sell your health information without your authorization.
We will not use or disclose your health information without your authorization, except as described in this Notice.

Disclosures for Treatment, Payment and Health Care Operations
When state law requires us to obtain your written permission to use or disclose your health information for treatment, payment or health care operations, we will do so.  However, there are also situations where we may use or disclose your information for treatment, payment, and health care operations without your permission.

We may use or disclose your health information for treatment purposes.
For example: Information obtained by members of your health care team will be documented in your record and used to determine the course of your treatment. Health care team members may communicate with each other personally and through your health record to coordinate your care. We may provide your physician or other health care provider with copies of reports that may help determine your future treatment.
We may also disclose your information to another health care provider for its payment purposes or its health care operations.  These exchanges may be done through electronic health information exchange networks.

We may use or disclose your health information for payment purposes.
For example: We may send your bill to you or your insurance company. Your bill may contain information that identifies you, as well as your diagnosis, procedures and supplies used.  However, if you pay for a health care service or item out-of-pocket in full and request in writing that we not provide information to your health insurer, we will comply with your request unless a law requires us to share that information with them.  

We may use or disclose your health information for health care operations purposes and internal business practices.
For example: Members of the medical staff, members of the quality improvement team, or the risk or quality improvement manager may use information in your health record to assess your care and outcomes. This information is used in our ongoing efforts to improve the quality and effectiveness of the health care and services we provide.

Other Disclosures That May be Made Without Your Authorization
Unless we are otherwise restricted from doing so, we may also use or disclose your information for the following purposes without your authorization:
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:  We 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.

Hospital Directory:  Unless state or federal law otherwise restricts us, or unless you instruct us not to, we may release your location within the hospital to people who ask for you by name. In addition, unless you instruct us not to, we may release your name, location, and religious affiliation to members of the clergy.

Business Associates:  Some services of our organization are provided through contractual arrangements with business associates. These include radiology, certain laboratory services, supplemental staffing, transcription, and data management. When services are provided by a business associate, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your insurance company for those services. In addition, we may disclose your health information to accrediting agencies and certain outside consultants. Our business associate must use appropriate safeguards to protect your health information.

Funeral Directors/Medical Examiners:  We may disclose your health information to funeral directors, medical examiners and/or coroners consistent with applicable law so that they can carry out their duties.

Organ Procurement Organizations: Consistent with applicable law, we may disclose your 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.

Research:  We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. In addition, we may disclose information to researchers in preparation for research.

Marketing:  We may use your information to provide you with information regarding a health-related product or service provided by MHS or an MHS affiliate or information regarding your treatment or care, such as appointment reminders, information about treatment alternatives, and/or in face-to face encounters.

Fundraising:  We may use your name and limited demographic information to contact you as part of an MHS fundraising effort.

Food and Drug Administration (FDA):  We may disclose to the FDA, or an entity subject to FDA jurisdiction, your health information for public health purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity for which that person has responsibility. For example, your information may be disclosed in connection with the reporting of an adverse event, product defect, product tracking or to provide post marketing surveillance information.

Workers' Compensation:  We may disclose your 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:  When required or permitted by law, we may disclose your health information to public health or legal authorities responsible for preventing or controlling disease, injury or disability or performing other public health functions. In addition, we may disclose your health information in order to avert a serious threat to health or safety.

Specialized Governmental Functions:  We may disclose your health information for military and veterans activities, national security and intelligence activities and similar special governmental functions as required or permitted by law.

Correctional Institutions:  If you are 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 your health information for law enforcement purposes as required or permitted by law or in response to a valid subpoena, court order or other binding authority.

Disclosures Required by Law:  We may use or disclose your health information as required by law provided such use or disclosure complies with and is limited to the relevant requirements of such law

Health Oversight Agencies:  We may disclose your health information to an appropriate health oversight agency, public health authority or attorney involved in health oversight activities.

Judicial and Administrative Proceedings: We may disclose your health information for judicial or administrative proceedings as required or permitted by law or in response to a valid subpoena, court order or other binding authority.

ORGANIZED HEALTH CARE ARRANGMENT
Two of the MHS affiliates — Nebraska Methodist Hospital (including Methodist Women’s Hospital) and Jennie Edmundson Hospital — are clinically integrated care settings in which patients receive care from both hospital staff and independent providers who belong to the Medical Staff.  These Hospitals and their Medical Staff must be able to share protected health information freely for treatment, payment and health care operations.

Therefore, each Hospital and all eligible providers on the Hospital's Medical Staff have entered into an "organized health care arrangement" or OHCA. Under the OHCA, each Hospital and the eligible providers will:
•    Use a joint notice of privacy practices (this Notice) for all inpatient and outpatient visits;
•    Obtain a single signed acknowledgment of receipt;
•    Share protected health information from inpatient and outpatient hospital visits with eligible providers so that they can help the Hospital with its health care operations; and
•    Follow the privacy and information practices described in this Notice. Each OHCA participant is individually responsible to follow the practices in this Notice.

THIS NOTICE SERVES AS THE JOINT NOTICE OF PRIVACY PRACTICES OF THE ORGANIZED HEALTH CARE ARRANGEMENT FOR EACH OF THE MHS HOSPITALS LISTED ABOVE.

Who is included?  The participants in each OHCA include the MHS affiliate Hospital and all eligible providers on its Medical Staff. Eligible providers are providers who are themselves covered health care providers under HIPAA.

What sites are included?  Each OHCA covers only the MHS affiliate Hospital and its outpatient surgical, rehabilitation and other ancillary service sites. The OHCA does not cover the private offices of the providers or their information practices there or at other practice locations.

Nebraska Health Information Initiative (NeHII)
NeHII is a state-wide, internet-based, health information exchange. NeHII is sponsored by Nebraska health care providers and health insurers who share and use your information for treatment, payment or health care operations purposes. Using NEHII, participating providers and health insurers can see certain health, demographic and payment information (your health information) in each other's records. They can use this information for treatment, payment or health care operations.
MHS is a participant in this initiative. Because of this, all MHS patients are included in the NeHII information exchange unless they specifically request to opt-out of NeHII.

For More Information or to Report a Problem
If you have questions or would like additional information, you may contact the Privacy Officer or Director of Health Information Management at this MHS affiliate. If you believe your privacy rights have been violated, you can file a complaint with the MHS Privacy Officer at the phone number listed at the beginning of this Notice, or with the Office of 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/. We will not retaliate against you for filing a complaint.

Effective Date: September 23, 2013