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Privacy Notice

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

We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. Law requires us to:

  • Make sure that medical information that identifies you is kept private;
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
  • Follow the terms of the notice that is currently in effect.

Throughout this Notice, "we" or "our" refers to the hospital, its departments, employees, students and volunteers, and members of the Medical Staff while they are performing services in the areas covered by the Notice. "You" or "your" refers to you or your personal representative or other person legally authorized to make health care decisions for you. "Protected Health Information" is information about you, including demographic information that may identify you and that relates to your past, present, future physician health and related health care services.

WHO WILL FOLLOW THIS NOTICE

This Notice of Privacy Practices applies to Kootenai Health, Kootenai Clinic, Heart Clinics Northwest, Kootenai Outpatient Surgery, Kootenai Outpatient Imaging and Kootenai Health Foundation; its employees, staff and other hospital personnel; healthcare students and all the volunteers who we allow to help you while you are receiving services. This Notice of Privacy Practice also applies to all members of the Medical Staff of the hospital concerning the services they perform in the above noted areas. Protected health information may be shared and exchanged with members of the medical staff for treatment, payment, and health care operations. However, members of the medical staff, including your personal physician, may have different privacy policies and practices relating to their use or disclosure of protected health information created or maintained in their clinic or office.

1. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by a nurse, nurse practitioner, our office staff or others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of Kootenai Health.

Following are examples of the types of uses and disclosures of your protected health information that Kootenai Health will use for treatment, payment and health care operations. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

We may include certain limited information about you in the hospital while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, good, etc.) and your religious affiliation. The information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know
how you are doing. 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.

Kootenai Health participates in the Idaho Health Data Exchange (IHDE). The IHDE allows medical professionals to have access to vital patient information at the point of care. If you wish to not have your medical information made available through IHDE, you must complete an opt−out form. These are available through the Registration areas or the Medical Records Department.

  • For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students, clergy, or others who are involved in your care. For example, a doctor treating you for a broken leg may need to know if you have
    diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work
    and X−rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as long term care facilities or others we or your physician use to provide services that are part of your care.
  • For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your
    health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
  • Health Care Operations. We may use and disclose medical information about you for healthcare operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you or we or our designee may send you a patient satisfaction survey. We may also combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. We may also disclose information to doctors, nurses, technicians, health care students, and other hospital personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
  • Health−Related Benefits and Services. We may use and disclose medical information to tell you about health related benefits, services, or medical education classes that may be of interest to you.
  • Incidental Uses and Disclosures. There are certain incidental uses or disclosures of your information that may occur while we are providing service to you or conducting our business. For example, after surgery the nurse or doctor may need to use your name to identify family members that may be waiting for you in the waiting area. Other individuals waiting in the same area may hear your name called. We will make reasonable efforts to limit these incidental uses and disclosures.
  • Business Associates. We will disclose your medical information to our business associates and allow them to create, use and disclose your medical information to perform their job. These include but are not limited to: auditing, accreditation, legal services, and consulting services. For example, we may disclose your medical information to an outside billing company who assists us in billing insurance companies. These outside companies are called “business associates” and they contract with us to keep any PHI received from us confidential in the same way we do. These companies may create, receive or disclose PHI on our behalf.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that Kootenai Health has taken an action in reliance on the use or disclosure indicated in the authorization.

  • Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. We will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.
  • Fundraising Activities. We may use certain information about you (name, address, telephone number, dates of service, age, gender, date of birth, department of service, treatment physician, outcome information, and health insurance status) to contact you in the future to raise money for Kootenai Health. We may also provide this information to the Kootenai Health Foundation for the same purpose. The money raised will be used to expand and improve the services and programs we provide the community. If you do not want the Kootenai Health to contact you for fundraising efforts and you wish to opt out of these contacts, or if after opting out you wish to opt back in, you must notify our Privacy Officer in writing. You will be asked to complete the Request to Restrict Protected Health Information form.

KOOTENAI BEHAVIORAL HEALTH ADMISSIONS

Federal law and regulations protect the confidentiality of alcohol and drug abuse patient records maintained by this program. Generally, the program may not say to a person outside of the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless one of the following conditions are met:

  • The patient consents in writing;
  • The disclosure is allowed by a court order;
  • The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation;
  • Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations;
  • Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime;
  • Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law or appropriate state or local authorities.

Other Permitted and Required Uses and Disclosures that may be made with your Authorization or Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your nurse or practitioner may, using professional judgment, to determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

  • Individuals Involved in Your Healthcare or Payment for Your Care. We may release medical information about you to a caregiver/friend or someone identified by you. We may also give information to someone who helps pay for your care. You may restrict who information is provided to by communicating with your healthcare provider. If you are incapacitated and/or in an emergency situation, information may be shared with others. Information disclosed will be relevant to that person’s involvement in your care, payment and/or for notification purposes.
  • Emergencies. We may use or disclose your protected health information in an emergency treatment situation. If this happens Kootenai Health shall try to obtain your acknowledgement as soon as reasonably practicable after the delivery of treatment. If Kootenai Health is required by law to treat you and the clinician has attempted to obtain your acknowledgement, but is unable to obtain your acknowledgement, he or she may still use or disclose your protected health information to treat you.
  • Communication Barriers. We may use and disclose your protected health information if Kootenai Health attempts to obtain acknowledgement from you, but is unable to do so due to substantial communication barriers and the clinician determines, using professional judgment, that you intend to consent to use or disclosure under the
    circumstances.
  • Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your authorization. These situations include:

  • Required by Law. We may use or disclose your protected health information to the extent that law requires for the use or disclosure. This use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
  • Public Health Risks (Health and Safety to you and/or others). We may disclose medical information about you for public health activities. We may use and disclose medical information about you to agencies when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. These activities generally include the following:
    - To provide public schools immunization records:
    - To prevent or control disease, injury or disability;
    - To report births and deaths;
    - To report child abuse or neglect;
    - To report reactions to medications or problems with products;
    - To notify people of recalls of products they may be using;
    - To notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition;
    - To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure when required or    
      authorized by law.
  • Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and
    compliance with civil rights laws.
  • Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute but only if reasonable efforts have been made to notify you of the request or to obtain an order from the court protecting the information requested.
  • Coroners, Medical Examiners, and Funerals. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out
    their duties.
  • Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
  • Law Enforcement. We may release medical information if asked to do so by a law−enforcement official:
    - As required by law, including reporting wounds and physical injuries;
    - In response to a court order, subpoena, warrant, summons or similar process;
    - To identify or locate a suspect, fugitive, material witness, or missing person;
    - About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
    - About a death we believe may be the result of criminal conduct;
    - About criminal conduct at the hospital; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who 
      committed the crime.
  • Military. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
  • National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state.
  • Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work−related injuries or illness. Please see specific regulations for details on what can be released.
  • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary:

    - For the institution to provide you with health care.
    - To protect your health and safety or the health and safety of others.
    - For the safety and security of the correctional institution.
    - For the health and safety of individuals and officers or other persons responsible for the transporting of inmates or their transfer from one institution, facility or setting to another.
    - For Law enforcement on the premises of the correctional institution and
    - For the administration and maintenance of the safety, security, and good order of the correctional institution.
  • Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the Health Insurance Portability Accountability Act, Section 164.500 et. Seq.
    As of November 30, 2009 HIPAA has been amended to reflect the Health Information Technology for Economic and Clinical Health Act (the HITECH act) which was part of the American Recovery and Reinvestment Act of 2009. HITECH amends regulations as they relate to the imposition of civil money penalties for breaches of electronic medical records into tiers of blame and intent of the breach.
    The HITECH act also changes business associate contracts between the covered entity, hereby known as Kootenai Health and their business associates. Under previous agreements our Business Associates agreed to HIPAA regulations, but were not responsible for breaches of security or privacy. New regulations state that Business associates are subject to direct enforcement by both the Department of Health and Human Services and individual state attorneys.
    In case of a breach of electronic medical records by Kootenai Health or a Business Associate the affected individual (client) will be notified. The rule requires that the notification will be in plain language so the client can understand what happened, when it happened and what information was revealed. Kootenai Health will give the client steps to protect them from any other harm. A summary of how the breach is being handled and remediated will be given to the client as well as contact information for further questions that the client may have.

2. Your Rights as a Patient of Kootenai Health

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

  • You have the Right to Inspect and Copy your Protected Health Information. You have the right to inspect and receive a copy (paper or electronic) of your medical information that may be used to make decisions about your care including medical and billing records. To request a copy of your medical information that may be used to make decisions about you, submit your request in writing to the Medical Records department. For PHI in a designated record set that is maintained in an electronic format you can request an electronic copy of such information. We may deny our request to see psychotherapy notes; information compiled in anticipation of legal proceedings; information that is protected by applicable law; and information that may result in substantial harm to you or others if disclosed. We may charge you a reasonable cost−based fee for providing the records.
  • You have the right to request a restriction to your Protected Health Information. A patient may request not to have PHI disclosed to a health plan for purposes of payment and/or health care operations following the payment in full (out of pocket, self pay) or following arrangements with Business Services to pay for services received. For example if a patient pays for a service completely out of pocket and asks Kootenai Health not to tell his/her insurance company about it, we will abide by this request. To request this restriction you must contact the Medical Records Department or the Privacy Officer. This request must be made in writing by completing the Request to Restrict Protected Health Information form. We reserve the right to terminate any previously agreed to restrictions (other than a restriction we are required to agree to by law). We will inform you of the terminations of the agreed to restriction and such termination will only be effective with respect to PHI created after we inform you of the termination.
  • You have the right to request additional restrictions to your protected health information. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations or to certain family members or friends identified by you who are involved in your care or payment for your care. We are not required to agree to a requested restriction. If we agree to a restriction, we will comply with the restriction unless an emergency or the law prevents us from complying with the restriction, or until the restriction is terminated. We will ask you to complete the Request to Restrict PHI form.
  • You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We normally contact you by telephone or mail to the address you provided upon admission. You have the right to request that we contact you by some other method or at some other location. We will not ask you to explain the reason for your request. We will accommodate reasonable requests. We may require that you explain how payment will be handled if an alternative means of communication is used.
  • You have the right Request an Amendment to your protected health information. 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 of your designated record set for as long as we maintain this information. In addition, you must provide a reason that supports your request. To request an amendment, your request must be made in writing and submitted to the Manager of Medical Records. We will ask you to complete an Amendment of PHI form. In certain circumstances we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal. In addition, we may deny your request if you ask us to amend information
    that:
    - Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
    - Is not part of the medical information kept by or for the hospital;
    - Is not part of the information which you would be permitted to inspect and copy; or
    - Is accurate and complete.
  • Right to an Accounting of Certain Disclosures. You have the right to request and receive an accounting of disclosures we have made of your protected health information for certain purposes after April 14, 2003. This right does not extend to disclosures made to you; for treatment, payment, or health care operations; pursuant to a facility directory; to family members or others involved in your health care or payment; for notification purposes; or pursuant to an authorization. You have a right to receive the first accounting within the first 12−month period free of charge. We may charge a reasonable cost−based fee for all subsequent requests during that 12−month period. To request this list or accounting of disclosures, you must submit your request in writing to the Manager of Medical Records. We will ask you to complete a Request for an Accounting of Certain Disclosures form. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003.

You have the right to request and receive a review of a denial of access by a licensed health care professional who did not participate in the original decision to deny the individual’s request for access. In the event that Kootenai Health has denied access, under specific circumstances (e.g. If a licensed health care professional determines it may harm the individual or others), you have the right to request and receive a review of the denial.

COMPLAINTS

  • If you believe your privacy rights have been violated, you may file a complaint with Kootenai Health by contacting the Privacy Officer listed below or the Secretary of the Department of Health and Human Services. ALL complaints must be submitted in writing.
  • Will not perform intimidating or retaliatory actions against you for exercising any of your rights for filing a compliant against Kootenai Health.

CHANGES TO THIS NOTICE

We reserve the right to change the terms of our Notice of Privacy Practices at anytime, and to make the new Notice provisions effective for all protected health information that we maintain. If we materially change our privacy practices, we will prepare a new Notice of Privacy Practices, which shall be effective for all protected health information that we maintain. We will post a copy of the current Privacy Notice on our website at www.kootenaihealth.org. You may obtain a copy of the current notice in our registration area, or by contacting the Privacy Officer identified below, or visit our website at www.kootenaihealth.org for an electronic copy.

PRIVACY CONTACT

If you have any questions about this Notice, or if you want to object to or complain about any use or disclosure, or exercise any right as explained above, please contact:

Christine M. Curtis
Medical Records Manager/Privacy Officer
Kootenai Health
2003 Kootenai Health Way
Coeur d’Alene, ID 83814
(208) 666−2214

Version: 9.0
Effective Date: September 23, 2013 999888−020