Dear
Franciscan Skemp Patient:
At
Franciscan Skemp Healthcare we have found that delivering high quality healthcare
begins with respect. It is a key component of our organization�s mission and
part of what we convey to each other in all that we do. One important facet of
our culture of respect is our understanding of your right to privacy as one of
our patients. This privacy not only encompasses our relationship and
interaction with you while at one of our facilities for care, but also the
information we collect and keep for you as part of your care.
Recently, the Federal Government established new
regulations regarding the use and protection of medical and health information.
These new rules apply to most hospitals and doctor groups in the United States
and are intended to standardize privacy protections covering medical
information. While at Franciscan Skemp we have always made it a priority to
treat your medical information in confidence, we are now required to adhere to
these new, more formal, standards.
The
documents included with this message are the Franciscan Skemp Healthcare
Notice of Privacy Practices and an acknowledgement form. Presenting them to
you, and requesting you sign the form acknowledging the fact you received them,
are part of these new regulations. The notice is yours to keep. Please return
the signed acknowledgment form to the person who gave you these materials.
Signing the form means only that you have received the notice, and in no way
affects the care you will receive at Franciscan Skemp.
If
you have any questions about the privacy notice or the acknowledgement form,
please feel free to contact our Privacy Officer at 608-791-3968.
Thank
you. We are pleased to be of service to you and your healthcare needs.
Sincerely,
Robert Nesse, MD
President & CEO
Franciscan Skemp Healthcare
Notice of Privacy Practices
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.
WHERE THIS APPLIES
This Notice applies to all health care providers at
all Franciscan Skemp Healthcare service locations in Iowa, Minnesota and
Wisconsin (including clinics, acute care, nursing homes, pharmacies, etc.).
This notice also applies to other health care providers that come to Franciscan
Skemp to care for patients (such as physicians, physician assistants, therapists,
other health care providers that are not employed by the hospital, emergency
service providers, medical transportation companies, and medical equipment
suppliers).� These other health care
providers may follow different practices at their own offices or facilities.
The entities listed above sometimes work together to
provide collaborative care to patients. In order to accomplish this, these
entities may share Protected Health Information for treatment, payment
and health care operations.
�Protected Health Information� means any information
whether oral, electronic, or paper, which is created or received by Franciscan
Skemp and relates to a patient�s health care or payment for the provision of
healthcare.)
How Franciscan Skemp Handles
Your Medical Information
�Use� is the sharing of protected health information
within Franciscan Skemp. At Franciscan Skemp, providers, nurses and other
health care professionals work together for your good health. All caregivers
record information about you in a Franciscan Skemp medical record. (This
information is essential to the care Franciscan Skemp provides, and this is the
most important way Franciscan Skemp caregivers communicate with one another.)
Providers from different specialties may have a role in
your care, and the medical record of this care may include, but is not limited
to, reports from:
n Your provider(s)
n Nurses, therapists and other
caregivers
n Lab test results
n Radiology reports
n Your medical history
n Other medical data
Bringing all of this information together in the
medical record makes it possible for Franciscan Skemp to care for you
thoroughly and efficiently.
Everyone who works at Franciscan Skemp is required to
protect your medical information. Our providers and staff are expected to look
at your medical information only when necessary, such as for treatment, payment
and health care operations.
�Disclosure� means the release of your protected
health information outside of Franciscan Skemp. How Franciscan Skemp discloses
your information is set forth in the Uses and Disclosures of Protected Health
Information section of this document.
Franciscan Skemp Duties
Throughout this Notice, references to the use and
disclosure of your protected health information refer to information found in
your general medical record. When state and federal privacy laws differ, and
state law is more protective of your information or provides you with greater
access to your information, then the respective state law will override federal
law.� You may see references to
behavioral health treatment records that reflect these additional protections.
Fulfillment of These Duties
n Franciscan Skemp makes every effort to maintain the
confidentiality of medical information.
n Franciscan Skemp takes necessary precautions against
inappropriate use or disclosure of information.
n Employees shall access ONLY the information needed to
do their jobs.
Uses and Disclosures of
Protected Health Information
Part I � Treatment, Payment and
Health Care Operations
Any uses and disclosures, other than those specified
in this section, will be made only with your written authorization, which may
later be revoked by you, except to the extent that your authorization has
already been relied upon.
Treatment
Franciscan Skemp will use and disclose your protected
health information, including behavioral health treatment records, to provide,
coordinate or manage your care and continuing care outside of Franciscan Skemp.
This includes communication and consultation among health care providers,
nurses, technicians and other members of your medical team. For example,
following orthopedic surgery, your provider might refer you for rehabilitation.
Medical information about you will be shared to ensure continuity of your care.
Payment
Franciscan Skemp uses your protected health
information to create bills and collect payment from insurance companies,
Medicare and other payors. This requires providing your medical information to
your insurance company to show that Franciscan Skemp provided medical services
to you.
In the case of contracted behavioral health treatment,
treatment records may be disclosed to a state or county department for the sole
purpose of billing or collection for those particular patients without written
authorization.
Health Care Operations
Franciscan Skemp uses protected health information for
various internal activities such as monitoring and improving patient care, educational
and training purposes, preparing for federal regulatory reviews, managing
health care operations, and improving healthcare services. Here are some
examples:
n Protected health information is used to monitor our
programs and to ensure patient safety.
n Protected health information is used to respond to
patient complaints or concerns regarding quality of care.
n State reviewers are allowed to inspect patient records
to ensure compliance with state and federal programs, such as Medicare.
Franciscan Skemp facilities in Minnesota and Iowa are
required by law to obtain your written consent to disclose your medical
information outside of Franciscan Skemp or related entities for treatment,
payment or health care operations.� You
would not need to provide consent in cases of medical emergency, within related
health care entities when necessary for current treatment, or to third parties
who requested or paid for independent medical exams.
Patient Contacts
At times, Franciscan Skemp will use protected health
information such as your name, address and general medical condition to contact
you to:
n Provide appointment reminders
n Provide information about treatment alternatives
n Provide health-related benefits or services that may
be of interest to you
Philanthropy
Franciscan Skemp, through our philanthropic arm
(Franciscan Skemp Foundation, Inc.), may contact you to raise funds to help
sustain our healing mission. When conducting fundraising activities, Franciscan
Skemp may access only your basic demographic information (such as name and
address) and the dates you were treated at Franciscan Skemp. You may receive
letters or other publications asking you to consider making a tax-deductible
contribution to Franciscan Skemp. Franciscan Skemp does not sell or rent
patients� names or addresses to any outside organization.
Directory
In our hospital settings, Franciscan Skemp will use
your name, location in the facility and religious affiliation (should you
choose to provide this) in the Patient Directory. This allows us to help your
family members and loved ones reach you while you are in the hospital. For
example, a relative may wish to visit you in the hospital and would need to
know your hospital room number. In our clinics, a family member meeting you for
an appointment may have forgotten which floor your appointment is on. We may
provide location information to your family member upon request.
n This information is shared only with those asking
about you by name.
n You can choose to be excluded from the Patient
Directory.
n Franciscan Skemp will not identify you in the Patient
Directory as receiving, or having received, behavioral health treatment without
your written authorization.
Individuals Involved in Care
and Notification
Franciscan Skemp may not disclose protected health
information to a family member or friend involved with your care, or handling
your bills, unless you provide written authorization, except in the case of an
emergency. If family or friends are present while care is being provided,
Franciscan Skemp will assume your companions may hear the discussion, unless
you object. Franciscan Skemp will share limited protected health information to
notify a person authorized by you of your location, condition or death.
A �person authorized by you� is defined as:
n A parent, guardian or legal
custodian of a minor child
n The guardian of an incompetent
adult
n The healthcare agent designated
in an incapacitated patient�s health care power of attorney
n The personal representative or
spouse of a deceased patient
n If no spouse survives you,
�person authorized by you� also means an adult member of your immediate family.
In the case of behavioral health treatment, except
drug and alcohol treatment programs, Franciscan Skemp may release the following
protected health information from the treatment record to a spouse, parent,
adult child or sibling, provided they are directly involved in, or are
monitoring, the patient�s treatment and that authority has been verified by the
patient�s treatment provider:
n A summary of the patient�s diagnosis and prognosis
n The medication list
n The treatment plan
Unless the patient has been adjudged incompetent, the
treatment provider will notify the patient about the release of this protected
health information.
In the case of behavioral health treatment, Franciscan
Skemp may:
n Notify a spouse, parent or child that an individual is
an inpatient
n Provide a patient�s attorney and guardian ad litem, as
well as County Corporation Counsel, the patient�s protected health information
to prepare for matters related to detention, admission or commitment�
n Release protected health information that would assist
in the apprehension of a patient who has left the behavioral health unit
without permission
You have the right to request a restriction on the
above notifications. Please refer to the Right to Request Restrictions section
of this document.
Emergency Circumstances
Franciscan Skemp may disclose behavioral health
treatment records to a licensed provider who has determined that the life or
health of a patient is in danger, and treatment without the behavioral health
treatment record could be injurious to the patient�s health. Such disclosure
shall be limited to that part of the records necessary to meet the medical
emergency.
Medical Research
Federal regulations permit the use or disclosure of
your protected health information in medical research under very stringent
conditions. Research studies at Franciscan Skemp are reviewed and approved by
an Institutional Review Board (IRB). Federal law now requires that IRBs must
take into account the researcher�s plans for maintaining the confidentiality of
protected health information. If you are a private pay patient, you may request
that your protected health information not be used in medical research.
State laws require you to sign a separate written authorization
if you want Franciscan Skemp to be able to use your medical information for
medical research. This authorization is needed before Franciscan Skemp can
share research results outside of Franciscan Skemp.
Part II � Other Potential
External Disclosures
Authorized or Required by
Law
Franciscan Skemp will use or disclose your protected
health information, including behavioral health treatment records, when
authorized or required by a federal or state statute, regulation or court
opinion.
To Avert a Serious Threat of
Harm
Franciscan Skemp will use and disclose your protected
health information when it is necessary to protect you or the community from
imminent and substantial danger. As an example, a provider may report your name
and other relevant information to the Department of Transportation if the
provider believes that your vision or another medical condition would affect
your ability to safely drive a car.
Organ and Tissue Donation
If Franciscan Skemp professionals determine that a
patient might be a candidate for organ or tissue donation, Franciscan Skemp
will disclose your protected health information to organizations that handle
organ procurement, or organ, eye or tissue donation banks, or other
organizations to make organ or tissue donation and transplantation possible.
Military and Veterans
Under federal regulations, if a patient is a member of
the United States Armed Forces, Franciscan Skemp is permitted to release
protected health information as required by military authorities.� Franciscan Skemp also may release protected
health information about foreign military personnel to the appropriate foreign
military authority.� When the military organization
is sponsoring the medical evaluation, the patient�s medical information is
shared with both the patient and the sponsoring organization.� Patients being evaluated on behalf of the
military are aware of these arrangements.
State laws generally require your consent in order to
make such disclosures unless another federal law requires the disclosure.
Government Agency Requests
Franciscan Skemp will disclose your protected health
information, including behavioral health treatment records, as requested by
federal or state authorities under certain circumstances, only in response to a
written request. Examples are:�
n Financial audits
n Program monitoring and evaluation
n Facility licensure
n Individual certification
Correctional
Institutions/Department of Corrections
Franciscan Skemp will disclose an inmate�s protected
health information to the medical staff of the institution in which an inmate
is confined, to the receiving institution intake staff to which an inmate is
being transferred, or to a person designated by a jailer to maintain inmate
medication records. This will be done only if the disclosure is necessary for:
n Provision of healthcare
n Health and safety of the individual or other inmates
n Health and safety of the individual and persons
responsible for transporting or transferring them from one institution to
another
n Law enforcement on the premises of the institution
n Administration and maintenance of safety, security and
good order of the institution
Franciscan Skemp may release behavioral health treatment
records as follows:
n To the Department of Corrections pertaining to
registered sex offenders
n To the Department of Corrections if an individual is
incarcerated to determine if he/she is complying with an assessment or a driver
safety plan
n To correctional facilities responsible for supervision
of an individual receiving behavioral health treatment
n To parole officers responsible for supervision of an
individual receiving behavioral health treatment
n To a correctional officer who has custody of an
individual who is transferred or discharged from a treatment facility
Workers� Compensation
If you file an application for hearing with the
Department of Workforce Development, your protected health information will be
disclosed, including behavioral health treatment records, upon request.� Franciscan Skemp will disclose your
protected health information that is reasonably related to the condition for
which you are claiming compensation when you report an injury alleged to be
work-related.
Public Health Purposes
Franciscan Skemp may disclose your protected health
information for authorized public health purposes upon written request. These
purposes may include the following:
n To report suspected child abuse and neglect and to
assist in the prosecution of alleged child abuse or unborn child abuse,
including any related behavioral health treatment records
n To disclose to a person who may have been exposed to
HIV, under certain circumstances
n To report certain communicable diseases to the state epidemiologist
n To report neglect and suspected abuse of an unborn
child
n To report elder abuse and neglect, or to assist during
an elder abuse investigation
n Iowa and Minnesota law also requires reporting of
certain newborn metabolic diseases.�
n Iowa law requires reporting of farm accidents and head
injuries
Media Relations Activities
Franciscan Skemp may share extremely limited
information about patients who are seen as a result of an incident documented
in a public record. In these cases, if the news media contacts Franciscan Skemp
with a patient�s name, Franciscan Skemp may provide the patient�s condition in
general terms (such as �Fair� or �Good�).
Health Oversight Activities
Franciscan Skemp may disclose your protected health information
to health oversight agencies when authorized by law and upon written request.
Oversight activities can include licensure, accreditation, audits and
investigations. It is standard practice for regulatory agencies, such as the
Joint Commission on Accreditation of Healthcare Organizations, to review a
sample of medical records to ensure the quality of care provided. Other
instances in which Franciscan Skemp may disclose your protected health
information to the Department of Health and Family Services (DHFS) or law
enforcement agencies include, among others:
n If there is reasonable cause to believe that a
patient�s death was related to the use of a physical restraint, use of
psychotropic medication or suicide - this also includes related behavioral
health treatment records
n For investigation of a death of a child who resided in
a building operated by a child welfare agency, a resident of a community-based
residential facility, a resident of a nursing home, or a person admitted or
committed to a mental treatment facility
In the case of behavioral health treatment, Franciscan
Skemp may disclose certain treatment record information as follows:
n To DHFS or the director of the county department to
monitor treatment of individuals under its supervision
n Within DHFS as necessary to coordinate treatment of
individuals under its supervision
n To county departments to coordinate provision of
services and case management of individuals who have received either community
mental health, developmental disability, alcoholism or drug abuse services
within six (6) months preceding the request for information
Lawsuits and Other Judicial
Proceedings
Franciscan Skemp will disclose your protected health
information in response to a valid court order or a court issued subpoena. This
also applies to behavioral health treatment records.
Law Enforcement Activities
Franciscan Skemp will disclose your protected health
information to law enforcement officials:
n To report a gunshot wound
n To report serious burns and any other wound if
Franciscan Skemp has reasonable cause to believe that the wound occurred as a
result of a crime
n Verbally, upon a law enforcement official�s request to
identify or locate a suspect, fugitive, material witness or missing person,
including only the name, address, date and place of birth, social security
number, and physical characteristics
n From a behavioral health treatment record about a
crime committed on Franciscan Skemp premises, only if Franciscan Skemp believes
in good faith that the information is evidence of that criminal conduct.
Information disclosed is limited to the individual�s name and other identifying
information as well as information related to the apparent crimes.
n To report an unauthorized absence from the behavioral
health unit
n To investigate certain deaths, as outlined in the
Health Oversight Activities section in this Notice
n Upon request, when disclosure of identifying
information from a behavioral health treatment record is appropriate under the
circumstances
Coroners, Medical Examiners
and Funeral Directors
Franciscan Skemp may disclose protected health
information to a coroner or medical examiner following the death of a patient
for the purpose of completing a medical certificate or investigating a death.
Protected health information may only be disclosed with written authorization
to a funeral director when necessary to handle arrangements after death.
However, Franciscan Skemp may disclose to a funeral director or other persons who
prepare the body of a decedent for burial or other disposition the following
information about the decedent:
n HIV test results
n Certain diseases that may be transmitted by droplet,
contact or airborne transmission
n If the decedent was treated with radioactive materials
n Tissue donation status
n Whether a post-mortem examination is to be done
Part III - Patients� Rights
with Respect to Protected Health Information
Right to Inspect and Copy
You have the right to inspect and to request a copy of
your protected health information maintained in the Franciscan Skemp medical
record and behavioral health treatment record, except for limited information
that is restricted by Wisconsin law.
You or a person authorized by you may inspect your
medical record during regular business hours, upon reasonable notice. Most
patients have full access to inspect their entire medical record. To inspect
your records, you may schedule an appointment with the Franciscan Skemp Health
Information Management Services Department.
Franciscan Skemp may, on rare occasions, deny a
request to inspect and copy some information in the medical record. An example
would be if one parent is denied periods of physical placement by a court, that
parent will not be able to request a copy of their child�s medical record.
To obtain a copy of your medical record, you may
contact the Franciscan Skemp Health Information Management Services Department
to receive an authorization form to complete. A reasonable fee will be charged
to cover the expense of providing the copies.
If you are denied access to information, you may
request a review of that decision, except in limited circumstances. Another
uninvolved licensed healthcare professional within Franciscan Skemp will review
your request. That decision will be final.�
Contact the Franciscan Skemp Privacy Officer for more information.
Right to Request Amendment
You have the right to request that your protected
health information maintained in Franciscan Skemp medical record and behavioral
health treatment record be amended. You may send a written request to the
Privacy Officer at Franciscan Skemp. The request should include a reason to
support the amendment. Franciscan Skemp may deny it. If Franciscan Skemp denies
your request for an amendment, Franciscan Skemp will give you a written
explanation of the denial and will explain your rights.
Right to a List of Certain
Disclosures
You may submit your written request for a list of
certain disclosures of your protected health information to the Privacy
Official at Franciscan Skemp.
Right to Request
Restrictions
You have the right to ask Franciscan Skemp to restrict
the use or disclosure of your protected health information:
n To carry out treatment, payment or healthcare
operations
n To request that discussions about your condition or
care be between only you and your healthcare provider
n To family members or other persons involved in your
care
Your request must be in writing and submitted to the
Franciscan Skemp Privacy Officer. Generally, Franciscan Skemp is not able to
honor requests to restrict use of protected health information internally, as
it may hinder the ability to provide care to you.
Right to Request Alternate
Methods of Communication
You have the right to ask Franciscan Skemp to
accommodate reasonable requests to communicate with you in a certain manner
(such as by letter) or at a certain location without an explanation. For
example, you may ask that contact occur only at home. You may submit a written
request to the Privacy Officer specifying a certain type of communication with
you.
�
Right to Obtain a Paper Copy
of the Notice of Privacy Practices
You may submit a written request to obtain a paper
copy of the Notice of Privacy Practices to the Privacy Officer at Franciscan
Skemp at any time.
Complaints
If you believe Franciscan Skemp has violated your
privacy rights and you want to file a complaint, you can send a letter to:
Patient Representative
Franciscan Skemp Healthcare
700 West Avenue South
La Crosse, WI 54601
Or
Secretary
Department of Health and Human Services
200 Independence Ave., SW
Washington, D.C. 20201
Franciscan Skemp respects your right to file a
complaint. Franciscan Skemp would not, nor could it legally or ethically, take
action against you for filing a complaint. Franciscan Skemp reserves the right
to maintain an environment that serves the best interests of patients and
providers.
For more information about any Franciscan Skemp
privacy practice, contact the Franciscan Skemp Privacy Officer
at 608-791-3968.
Key Information about this Notice:
n The effective date of this Notice is April 14, 2003.
n Franciscan Skemp reserves the right to change the
terms of this Notice in accordance with the HIPAA rules or other laws and
reserves the right to make the new Notice provisions effective for all
protected health information.
n When the Notice is revised, it will be available upon
your request at Franciscan Skemp facilities, on our web site at
http://www.franciscanskemp.org, or by U.S. mail.
Copyright �� 2003 Franciscan Skemp Healthcare, Mayo Health System
