Privacy Practices and Patient Rights & Reponsibilites
NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
Revised June, 2006
Revised May, 2008
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. If you have any questions about this notice, please contact the Corporate Privacy Officer by telephone at 321.843.3333 or mail:
1414 Kuhl Ave.
Orlando, FL 32806.
Who Will Follow this Notice?
This notice describes Orlando Health's practices regarding the use and disclosure of your medical information, including use and disclosure by (a) any healthcare professional authorized to enter information into your medical record, (b) all departments and units of the system, (c) volunteers we allow to help you while you are in the facility, (d) all contracted services, and (e) all members of Orlando Health’s workforce.
All Orlando Health entities, sites and locations follow the terms of this notice, including: All Orlando Health hospitals, Orlando Regional Health Network, Physician Billing Services, Howard Phillips Center for Children & Families, HealthChoice, Orlando Health Foundation, home health services, ambulance services, outpatient centers, and all other Orlando Health sites and locations. Also included are staff and contracted physician services such as, but not limited to, emergency department physicians, pathologists, anesthesiologists, radiologists, hospitalists, physicians who interpret tests, and all other members of the medical staff when seeing patients in our facilities. These individuals, entities and facilities may share medical information with each other for treatment, payment or hospital operations purposes described in this notice.
Our Pledge Regarding Medical Information
We understand that information about you and your health is personal. We are committed to protecting that medical information. We create a record of the care and services you receive to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Orlando Health, whether made by our employees or your personal physician. Your personal physician may have different policies or notices regarding use and disclosure of medical information created in his/her office or clinic.
This notice tells you about the ways in which we may use and disclose information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to: make sure that health-related 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.
How We May Use and Disclose Medical Information About You
The following categories describe the ways that we use and disclose health-related information. For each category of uses or disclosures we will explain what we mean and try to give some examples. 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 within one of the categories.
We may use and disclose information about you to provide you with medical treatment or services. We may disclose information about you to physicians, nurses, technicians, medical students, or others who are involved in your care. (For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the physician may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals.) Departments of the hospital also may share medical information about you in order to coordinate the 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 family members, clergy or others who provide services that are part of your care.
We may use and disclose information about you so the treatment and services you receive can 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 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.
For Healthcare Operations
We may use and disclose information about you for normal hospital operations. These uses and disclosures are necessary to run the facility and make sure that all of our patients receive quality care. (For example, in the course of quality assurance and utilization review activities, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. Some of these reviews may be conducted by independent physicians who are members of the medical staff but not Orlando Health employees.) We may disclose medical information to business associates who provide contracted services such as accounting, legal representation, claims processing, quality assurance, accreditation, and consulting. If we do disclose medical information to a business associate, we will do so subject to a contract that provides that the information will be kept confidential. We may also combine medical information about patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to physicians, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are.
We may use and disclose information to contact you as a reminder that you have an appointment for treatment.
Follow-Up Phone Calls
As part of your treatment plan, there may be times that you will be contacted by Orlando Health staff via telephone after you have had service at one of its facilities. Examples include: (1) a follow-up phone call after discharge from the hospital to answer any questions from the patient or family or to determine that the patient is recovering appropriately; (2) a phone call to address patient satisfaction issues; or (3) a phone call to provide additional education or guidance to the patient on a particular topic related to their hospital stay. Such phone calls will be limited in number and are meant to ensure optimum recovery, patient satisfaction and education.
Treatment Alternatives and Health-Related Benefits and Services
We may use and disclose information to recommend or tell you about treatment alternatives and health-related benefits or services that may be of interest to you.
We will include certain limited information about you in the hospital directory if you are assigned a bed in one of our hospitals. This information may include your name, location in the hospital, general condition (fair, good, etc.) and religious affiliation. The directory information, except for your religious affiliation, may be released to people who 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. (This does not apply to behavioral health patients.) 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. If you do not wish to have this information included in the hospital directory, notify registration personnel. (A request not to be included in the hospital directory must be made for each visit.)
Individuals Involved in Your Care or Payment for Your Care
Unless you object, we may release information about you to a friend or family member who is involved in or helps pay for your medical care. We may also tell your family or friends your general condition and that you are in the hospital. 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.
Under certain circumstances we may use and disclose 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 are subject to a special approval process that evaluates a proposed research project and its use of medical information, trying to balance the research needs with the patient’s need for privacy of their medical information. Before we use or disclose information for research, the project will have been approved through this research approval process; however, we may disclose information about you to people preparing to conduct a research project to help them look for patients with specific medical needs, so long as the information they review does not leave Orlando Health. When our staff conducts a research project in which they look back at old medical records, your personal information will not be disclosed outside the hospital nor will you be identified in any reports. If a research project is conducted where your information cannot be held confidential, a separate process is in place for you to consent for this type of research.
We may follow-up your visit with us by sending to the address listed in your records a brief written survey about your satisfaction with the level of service provided to you. In some cases, the survey may be conducted by telephone or e-mail using the contact information listed in your medical record. In some instances, your name may be passed on to members of the service excellence team to investigate a complaint or corroborate an incident.
We may use certain information (name, address, telephone number, dates of service, age, and gender) to contact you in the future to raise money for Orlando Health. We may also provide this information to an institutionally-related foundation for the same purpose. The money raised will be used to expand and improve the services and programs we provide the community.
It is the policy of Orlando Health to not to use patient records to market our facilities or services. However, you may receive unsolicited materials promoting the programs, facilities or services of Orlando Health because your name and contact information appears on other publicly available lists or because you have subscribed to a membership program with us such as Life Rewards, HealthyWoman, etc.
If you do not wish to receive unsolicited information from Orlando Health, we will do our best to have your name purged from any lists we may use. To exercise your option not to receive unsolicited information from Orlando Health about our programs, facilities or services, please notify us in writing by sending your request to Orlando Health, Direct Marketing, Marketing Opt Out, 1414 Kuhl Ave., Orlando, FL 32806. Other options for opting out will appear on unsolicited marketing materials you receive from us.
As Required By Law
We will disclose information about you when required to do so by federal, state or local law.
To Prevent a Serious Threat to Health or Safety
We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures would only be to someone able to help prevent the threat.
Organ and Tissue Donation
If you are an organ donor, we may release information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.
Military and Veterans
If you are a member of the armed forces, we may release information about you as required by military authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.
We may release information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks
We will disclose information about you for public health activities as required by law. These activities generally include the following: (a) to prevent or control disease, injury or disability; (b) to report births and deaths; (c) to report child abuse or neglect; (d) to report reactions to medications or problems with products; (e) to notify people of recalls of products they may be using; (f) to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and (g) to notify the appropriate government authority if we believe you have been the victim of abuse, neglect or domestic violence.
Health Oversight Activities
We will disclose information to a health oversight agency for activities authorized by law. These oversight activities include: audits, investigations, inspections, and licensure that are necessary for the government to monitor the healthcare system, government programs, and compliance with applicable laws.
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose information about you in response to a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if we are assured that reasonable efforts have been made to tell you about the request or to obtain an order protecting the information requested.
We may release information if asked to do so by a law enforcement official: (a) in response to a court order, subpoena, warrant, summons or similar process; (b) to identify or locate a suspect, fugitive, material witness, or missing person; (c) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the patient agreement; (d) about a death we believe may be the result of criminal conduct; (e) about criminal conduct at the hospital; and (f) 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.
Coroners, Medical Examiners and Funeral Directors
We will release information to a coroner or medical examiner to identify a deceased person or determine the cause of death. We will also release information to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities
We may release information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
Protective Services for the President of the United States and Others
We may disclose information about you to authorized Federal officials so they may conduct special investigations and provide protection to the President or other officials and dignitaries.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official to provide you with healthcare, to protect your and other’s health and safety, or for the safety and security of the correctional institution.
Your Rights Regarding Medical Information About You
You have the following rights regarding the medical information we maintain about you:
Right to Inspect and Copy
You have the right to inspect and obtain copies of 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.) To inspect and copy medical information that may be used to make decisions about you, you must appear in person or submit your request in writing to: Orlando Health, Release of Information, MP 69, 1414 Kuhl Ave., Orlando, FL 32806. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy your medical information in certain limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare 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.
Right to 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 or for South Lake Hospital.
To request an amendment, your request must be made in writing and submitted to Orlando Health, Health Information Management, MP 97, 1414 Kuhl Ave., Orlando, FL 32806. In addition, you must provide a reason that supports 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: (a) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (b) is not part of the medical information kept by or for the hospital; (c) is not part of the information which you would be permitted to inspect and copy; or (d) is accurate and complete.
Right to an Accounting of Disclosures
You have the right to request an accounting (list) of certain types of disclosures we have made of medical information about you. We are not required to account for certain disclosures such as: (a) disclosures you authorize; (b) disclosures to carry out treatment, payment and healthcare operations; and (c) disclosures to persons involved in your care.
To request an accounting of disclosures, you must submit your request in writing to: Orlando Health, Release of Information, MP 69, 1414 Kuhl Ave., Orlando, FL 32806. Your request must state a time period, which may not be longer than six years, and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. There may be a charge for additional requests. 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.
Right to Request Restrictions
You have the right to request a restriction or limitation on our use or disclosure of information about you for treatment, payment or healthcare operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. (For example, you could ask that we not use or disclose information about a surgery you had to a particular family member.)
You may make this request orally to registration personnel and you will be designated as a “no publicity” for that episode of care. If you want to limit information we disclose about you for payment of your bill, you may be responsible for your bill. For all other restrictions, you must complete the “Request for Restrictions on Uses and Disclosures of Protected Health Information” form available at any Orlando Health admissions/registration center or from the Corporate Privacy Officer. You may contact the Corporate Privacy Officer at 321.843.3333 to request a form and one will be mailed to you. Completed forms must be mailed to Attn: Corporate Privacy Officer, Orlando Health, 1414 Kuhl Ave., MP 29, Orlando, FL 32806. We will reply to you within 60 days. 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 with emergency treatment.
Right to Request Confidential Communications
You have the right to request that we communicate with you in a certain way or at a certain location. (For example, you can ask that we only contact you at work or by mail.) If you want to request confidential communication, contact a Registration or Billing Office representative, Monday through Friday during regular business hours and/or during the registration process. We will not ask the reason for your request. We will accommodate all reasonable requests. Your request must include the address and/or telephone number where you want to be contacted.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice any time. You may obtain a copy of this notice at our website, southlakehospital.com, or at any facility’s information desk or admission/registration center.
Changes to this Notice
We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical 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 various locations indicating the effective date. Revised copies of this notice will be provided at your next visit.
If you believe your privacy rights have been violated, you may file a complaint with the facility or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the facility, contact Orlando Health, Attn: Corporate Privacy Officer, 1414 Kuhl Ave., MP 29, Orlando, FL 32806. 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 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 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 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.
SUMMARY OF THE FLORIDA PATIENT'S BILL
OF RIGHTS AND RESPONSIBILITIES
Florida law requires that your healthcare provider or healthcare facility recognize your rights while you are receiving medical care and that you respect the healthcare provider's or healthcare facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your healthcare provider or healthcare facility. A summary of your rights and responsibilities follows:
- A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
- A patient has the right to a prompt and reasonable response to questions and requests.
- A patient has the right to know who is providing medical services and who is responsible for his or her care.
- A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
- A patient has the right to know what rules and regulations apply to his or her conduct.
- A patient has the right to be given by the healthcare provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
- A patient has the right to refuse any treatment, except as otherwise provided by law.
- A patient has the right to be given, upon request, full information, and necessary counseling on the availability of known financial resources for his or her care.
- A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.
- A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
- A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
- A patient has the right to impartial access to medical treatment or accommodations, regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression.
- A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
- A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.
- A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.
- A patient is responsible for providing to the healthcare provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
- A patient is responsible for reporting unexpected changes in his or her condition to the healthcare provider.
- A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
- A patient is responsible for following the treatment plan recommended by the healthcare provider.
- A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the healthcare provider or health care facility.
- A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions.
- A patient is responsible for assuring that the financial obligations of his or her healthcare are fulfilled as promptly as possible.
- A patient is responsible for following healthcare facility rules and regulations affecting patient care and conduct.