Effective Date: August 3, 2022
Who Will Follow This Notice
This Notice describes the privacy practices of Peninsula, a division of Parkwest Medical Center, (“Peninsula”), as well as any health care professional authorized to enter information into a Peninsula healthcare record; all Peninsula departments and units; any member of a volunteer group that Peninsula allows to help patients while in Peninsula’s care; business associates of Peninsula; and all Peninsula employees, staff, and personnel.
Peninsula, its employees, staff, and personnel, and the health care professionals providing services at Peninsula participate in an “organized health care arrangement” that permits sharing of protected health information (“PHI”) to carry out treatment, payment and health care operations related to the arrangement as permitted by law. Additionally, Peninsula and the members of its organized health care arrangement participate in a master organized health care arrangement with Covenant Health and its wholly owned subsidiaries that permits Peninsula to share PHI for the same purposes under similar arrangements. Each of the participants in the organized health care arrangements remains solely responsible and liable for its/his/her own acts and omissions. These organized health care arrangements do not create a joint venture, partnership, agency, or employment relationship, and joint and several liability is not intended.
Records This Notice Covers
This Notice applies to all protected health information maintained by Peninsula, whether made by Peninsula personnel or received by Peninsula from other health or mental health care providers. Other health or mental health care providers may have different policies and notices regarding use and disclosure of PHI which they maintain.
Substance Abuse Treatment Records
Peninsula has programs for the treatment of drug and alcohol abuse, including without limitation, an Adult Intensive Outpatient Program (IOP), a grant-funded Women In Treatment IOP, and a Medication-Assisted Treatment program. The confidentiality of alcohol and drug abuse patient records maintained by these programs is protected by specific federal law and regulations. These programs may not disclose to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless (1) the patient consents in writing; (2) the disclosure is allowed by a court order; (3) the disclosure is to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation; or (4) the disclosure is permitted by law. Violation of the federal law and regulations by these “Part 2” programs is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. Federal law and regulations do not, however, protect any information about a crime committed by a patient either at a Part 2 program or against any person who works for such a program, or about any threat to commit such a crime. Further, federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. 42 U.S.C.§ 290dd-2; 42 C.F.R. Part 2.
Peninsula is required by law to keep protected health information private, to provide this Notice of our legal duties and privacy practices with respect to such PHI, to comply with the Notice currently in effect, and to notify affected individuals following a breach of unsecured PHI.
How We May Use and Disclose Health Information
The following categories describe different ways Peninsula and the organized health care arrangements in which Peninsula participates use and disclose your protected health information. Although not every use or disclosure in a category will be listed, all of the ways we use and disclose your information will fall within one or more of the categories.
Treatment. We may use and disclose protected health information to provide medical treatment. For example, different departments of Peninsula may share protected health information to coordinate the different things a patient needs, such as prescriptions and lab work. We may also disclose PHI to doctors, nurses, technicians, medical students, or other healthcare personnel involved in a patient’s care at Peninsula. We may disclose PHI to other health or mental health care providers and other individuals if necessary to assure treatment and care to you by the least drastic means appropriate to your liberty and interests. We may also disclose PHI as necessary for your continued treatment and care when your treatment and care moves to other health or mental health providers.
Payment. We may use and disclose protected health information as reasonably necessary to create bills and to process and obtain payments from organizations that pay for patient treatment. For example, we may provide a health insurer with information about treatment a patient received so the insurer will pay for the treatment. We may also tell a health insurer about a treatment a patient will receive to obtain prior approval, or to determine whether the insurer will cover the treatment. These examples are illustrations of instances when PHI may be used or disclosed for payment and are not intended to describe every instance in which PHI may be used or disclosed for payment. Peninsula substance abuse programs subject to federal regulation protecting patient confidentiality generally will obtain patient consent before disclosing information to obtain payment for services.
Health Care Operations. We may use and disclose protected health information as necessary for the operation of Peninsula. These uses and disclosures are necessary to run Peninsula and to ensure that all patients receive quality care. For example, we may use PHI for internal review of treatment or combine PHI about our patients to decide what additional services Peninsula should offer, what services are not needed, and whether certain new treatments are effective. We may use PHI to conduct overall quality assessment and improvement activities, to review the competence or qualifications of health care professionals, and to conduct fraud and abuse detection programs. We may also disclose PHI to doctors, nurses, technicians, medical students, and other Peninsula personnel for review and learning purposes.
Patient Contacts. We may contact patients to remind them of appointments for treatment or care or to recommend possible treatment options or alternatives. We may also contact patients to discuss health-related benefits or services of interest.
Individuals Involved in Patient Care/Payment for Care; Disaster Relief Agencies. We may release protected health information to a family member or friend involved in a patient’s care or payment for care. We may also release PHI to notify a family member, friend, or person responsible for a patient’s care of the patient’s location and general condition. We also may disclose PHI to a custodial agent for a state agency having custody of a patient, if necessary for the agency to properly perform its duties. We may disclose PHI to a disaster relief agency so a patient’s family can be notified of the patient’s condition, status, and location.
Research. We may use and disclose PHI necessary for research purposes. All research projects are subject to a special approval process that evaluates a proposed research project and its use of PHI, to balance the research needs with patients’ right to privacy. We may also disclose PHI to people preparing to conduct a research project (for example, to help them look for patients with specific medical needs), as long as the medical information they review does not leave Peninsula. In almost all other cases, we will obtain specific authorization if the researcher will have access to a patient’s name, address, or other information that reveals who the patient is.
As Required By Law or To Avert a Serious Threat to Health or Safety. We disclose protected health information when required by law. For example, we are required to disclose information when requested by a federally mandated protection and advocacy agency for a federally mandated function. We may also disclose PHI to comply with laws regarding reporting child abuse and neglect, as well as abuse, neglect, and exploitation of certain adults to state or local authorities without obtaining consent. We are also required by law to report drug overdoses in students and certain kinds of wounds or poisonings. We may use and disclose PHI, if necessary, to prevent or lessen a serious and imminent threat to the health or safety of the patient, another person, or the public. Any disclosure for this purpose would only be to someone able to help prevent or lessen the threat, which may include disclosure to the person threatened.
Public Health Activities. We disclose protected health information for certain public health activities, such as prevention or control of disease, injury, or disability; reporting births and deaths; reporting reactions to medications or problems with products; providing recall notification for products; notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition and notifying the appropriate government authority if we believe a patient is the victim of abuse.
Health Oversight Activities. We disclose protected health information to health oversight agencies for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure actions. Under certain circumstances, and for purposes of audit and evaluation only, Peninsula substance abuse programs may disclose PHI without specific consent to a health oversight agency conducting audit and evaluation on behalf of a federal, state, or local governmental agency that provides financial assistance to Peninsula or that is authorized by law to regulate Peninsula’s activities.
Law Enforcement. We release protected health information to law enforcement agencies and representatives as required to comply with a court order, subpoena, warrant, summons, or similar process authorized by law. We also may disclose PHI to report crimes committed on Peninsula premises (e.g., felonious acts of bodily harm and certain sexual offenses) and to give law enforcement authorities the names and access to potential witnesses, potential suspects, and the location of the crime. We also disclose PHI to law enforcement to comply with laws regarding the reporting of suspicious wounds and deaths. We are also required by law to report certain information to courts and law enforcement authorities regarding patients who are involuntarily committed to Peninsula Hospital following a court hearing.
Disclosures for Court and Administrative Legal Proceedings. We disclose protected health information in response to certain court or administrative orders or in response to subpoenas for information related to disclosures required by law, such as information regarding child or adult abuse, neglect or exploitation. Peninsula also discloses PHI to the extent necessary for involuntary hospitalization proceedings (commitment). Such disclosures may be made to health care providers, courts, attorneys, and witnesses involved in the commitment proceedings. Peninsula is also required to notify a patient’s parent (unemancipated minor patients), conservator, spouse, or adult next of kin that a patient has been committed, the basis of the commitment, and about legal proceedings for the commitment.
Coroners; Medical Examiners; and Funeral Directors. We release protected health information to coroners, medical examiners, and funeral directors, as necessary.
Organ and Tissue Donation. We release protected health information to organizations that handle organ procurement or organ, eye, or tissue transplantation.
Worker’s Compensation. Protected health information may be released to a worker’s compensation insurer or employer upon consent, as required by law, or as reasonably necessary to obtain payment.
Fundraising. We may contact you for fundraising for Peninsula. You can always opt out of receiving such communications.
Your Rights Regarding Medical Information About You
You have the following rights regarding the protected health information Peninsula maintains about you:
Right to Inspect and Copy. You or your legal representative may inspect or copy health records about you, other than certain records excepted by law. To inspect or copy records, you must submit a written request to a Peninsula Privacy Officer (contact 865-374-8010 for more information, including how to obtain records in electronic or paper format). We may charge a reasonable cost-based fee for copies. We may deny your request to inspect or copy only in limited circumstances. For example, if you are accused of abusing a patient who is a child, you may be denied access to the child’s records even though you are the parent. Also, if access to the records poses a substantial risk of serious harm to the health or safety of the patient or another person, Peninsula may refuse access to those records. If you are denied access, you may request the denial be reviewed. Another licensed health care professional chosen by Peninsula will review the request and 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 Request Amendments. If you think protected health information we have about you is incorrect or incomplete, you can ask us to correct the information. Requests for such amendments must be submitted in writing to a Peninsula Privacy Officer with a reason supporting the request. We may deny your request under certain circumstances, including if your records are already accurate and complete, but we will let you know of our decision within sixty days of your request.
Right to an Accounting of Disclosures. You may request a list (an “accounting”) of how we shared your protected health information for six years prior to the date you ask, who we shared it with, and why. To request an accounting, you must submit your request in writing to a Peninsula Privacy Officer. We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting per year for free, but will charge a reasonable, cost-based fee if you ask for another one within twelve months.
Right to Request Restrictions. You have the right to request a restriction on the protected health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on PHI we disclose about you to someone involved in your care or payment for your care, like a family member or friend. We are not required to agree to your request except for payment- and operations-disclosures to health plans not otherwise required by law, when the PHI relates to a health care item or services for which you or a responsible party has paid Peninsula in full. If we do agree to a request for restrictions, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to a Peninsula Privacy Officer. In your request, you must tell us what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply.
Right to Request Confidential Communications. You have the right to request we communicate with you about health matters in a certain way or at a certain location. For example, you can ask we only contact you at work or by mail. To request confidential communications, you must make your request in writing to a Peninsula Privacy Officer. We will not ask you the reason for your request and will accommodate reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You can ask for a paper copy of this Notice any time, even if you have agreed to receive the Notice electronically. We will provide you with a paper copy promptly. You may also obtain a copy of this Notice at our website, www.peninsulabehavioralhealth.org.
Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for PHI we already have about you, as well as any information we receive in the future. We will post a copy of the current Notice. We will provide you with a copy of the current Notice. In addition, each time you register or are admitted to Peninsula for services as an inpatient or outpatient, we will offer a copy of the current Notice in effect.
If you believe your privacy rights have been violated, you may complain to Peninsula or the U.S. Department of Health and Human Services. To file a complaint with Peninsula, contact a Peninsula Privacy Officer (call 865-374-8010 for more information). You may also contact the Covenant Health Integrity-Compliance Department Report line at (888) 731-3115. We may request that your complaint be submitted in writing. You will not be penalized for filing a complaint.
Authorizations/Other Uses and Disclosures of Health Information
Other uses and disclosures of protected health information not addressed in this Notice or by laws that apply to Peninsula are made only with written authorization by you or your representative. Written authorization by you or your personal representative is specifically required for sale of your health information, disclosures for marketing purposes, and most disclosures of psychotherapy notes. If you are an unemancipated child, your parent, guardian, or custodian may authorize disclosure. If a committed patient lacks capacity to make an informed decision regarding disclosure, a Treatment Review Committee may furnish authorization. In addition, your conservator, guardian ad litem, attorney-in-fact (who has been granted such power), caregiver, agent or surrogate health care decision-maker, and executor, administrator or personal representative generally may authorize disclosures of your PHI. An authorization permitting us to use or disclose PHI about you may be revoked, in writing, at any time, by the person who granted the authorization, by providing notice of such intent to revoke to a Peninsula Privacy Officer. If the authorization is revoked, we will no longer use or disclose PHI about you permitted by your written authorization. However, we are unable to take back any disclosures we have already made with your permission. Further, we are required to retain records of care that we provided to you.
You may contact a Peninsula Privacy Officer at 865-374-8010 for more information about this Notice or to obtain information on how to submit any requests or concerns in writing.