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Notice of Privacy Practices

Effective 10/01/2015

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 Mountain States Health Alliance Corporate Compliance Department at (423) 302-3345 or the Mountain States AlertLine at (800) 535-9057.

WHO WILL FOLLOW THIS NOTICE:

This notice summarizes the privacy practices of members of Mountain States’ Affiliated Covered Entity (ACE), which are health care facilities and other health care entities that are under MSHA’s common ownership or control and share privacy policies and procedures. These include, but are not limited to, the health care components of: Abingdon Physician Partners, Blue Ridge Medical Management Corporation, Community Home Care, Inc., Dickenson Community Hospital, Emmaus Community Healthcare, LLC., Franklin Woods Community Hospital, Indian Path Medical Center, Johnson City Medical Center, Johnson County Community Hospital, Johnston Memorial Hospital, Inc., Mediserve Medical Equipment of Kingsport, Inc., Norton Community Hospital, Norton Community Physicians Services, LLC., Russell County Community Hospital, Smyth County Community Hospital, Sycamore Shoals Hospital, Unicoi County Memorial Hospital, Wilson Pharmacy, Inc., and Woodridge Hospital.

As the members of Mountain States' ACE may change over time, please use this link for a current list of members of Mountain States Health Alliance’s ACE.

This notice applies to all departments, units, all healthcare professionals and others who may be involved directly or indirectly in your care at Mountain States entities such as employees, physicians, allied health professionals such as physician assistants and nurse practitioners, residents, students, volunteers, business associates and others affiliated with Mountain States. We may share your health information with each other for purposes described in this notice, including for our joint healthcare operations activities.

OUR PLEDGE TO YOU:

We understand that your health information is personal, and we are committed to protecting its privacy. We are required by law to:

  • Maintain the privacy of your health information
  • Give you this notice of our legal duties and privacy practices regarding your health information
  • Follow the terms of our Notice of Privacy Practices that are currently in effect; and
  • Notify you following a breach that compromises the privacy or security of your health information. 

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU:

RIGHT TO INSPECT AND COPY:

You have the right to request to inspect and obtain a copy of the health information that may be used to make decisions about your care or payment. To inspect and obtain a copy of your health information, you must submit your request in writing to the healthcare entity. There may be fees for the costs of copying, mailing or other supplies associated with your request.

RIGHT TO AMEND:

If you feel that health information we have about you is incorrect, you may ask us to amend the information. To request an amendment, your request must be made in writing and submitted to the healthcare entity. We may deny your request under certain circumstances. You will be informed of the decision regarding any request for amendment of your health information and, if we deny your request for amendment, we will provide you with information regarding your right to respond to that decision.

RIGHT TO AN ACCOUNTING OF DISCLOSURES:

You have the right to request a list of certain disclosures we make of your health information covering up to six years. We will include all disclosures except those for treatment, payment, health care operations, and certain other disclosures (such as those you asked us to make). To request this list of disclosures, you must submit your request in writing to the healthcare provider or facility. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list but will notify you of the cost involved and offer you the chance to withdraw or modify your request before any costs are incurred.

RIGHT TO REQUEST RESTRICTIONS:

You have the right to request a restriction on the health information we use or disclose about you for treatment, payment or health care operations. We are not required to agree to a request for restrictions, other than a request that we not disclose information to a health plan for payment or health care operations where the request relates only to a health care item or service for which we have been paid in full. If we do agree, 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 the healthcare provider or facility. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your health plan.

CONFIDENTIAL COMMUNICATIONS:

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. Your request must specify how or where you wish to be contacted and be submitted in writing. We will accommodate reasonable requests. 

RIGHT TO A PAPER COPY OF THIS NOTICE:

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may also obtain a copy of this notice at our website, www. MountainStatesHealth.com. 

English: View and download the printable PDF
Español: Ver y descargar el PDF imprimible

HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

The following describes different ways that MSHA entities may use and disclose health information that identifies you.

TREATMENT:

We may use health information to treat you or provide you with healthcare services. For example, we may tell your primary care physician about the care we provided you or give health information to a specialist to provide you with additional services.

PAYMENT:

We may use and disclose health information so that we or others may bill or receive payment from you, an insurance company or a third party for the treatment and services you receive. For example, we may give your health plan information about your treatment so that they will pay for such treatment.

HEALTHCARE OPERATIONS:

We may use and disclose health information for healthcare operations and administrative purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and for our operation and management purposes. For example, we may share information with doctors, nurses, medical students, and other personnel for learning purposes.

HEALTH INFORMATION EXCHANGE:

Mountain States participates in one or more electronic health information exchange networks. Through these health information exchanges, your information will be electronically available to other health care providers and other entities. These entities can access your Mountain States health information for your treatment or other permitted purposes. If you have questions about MSHA’s involvement in electronic health information exchange, please contact our Privacy Officer in the Corporate Compliance Department at 423-302-3345 or the Mountain States AlertLine at 1-800-535-9057.

FUNDRAISING ACTIVITIES:

We may disclose certain limited health information to our Foundation so that they may contact you regarding fundraising activities. You have the right to notify the Foundation at 423-302-3131 to request to not receive fundraising information.

FACILITY DIRECTORY:

We may list your information in our facility directory, unless you ask us not to.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE:

If you do not object, we may disclose relevant health information to a family member, friend, or other person involved in your medical care or who helps pay for your care. We may also disclose health information to a personal representative, who is a person who has legal authority to make healthcare decisions on your behalf.

BUSINESS ASSOCIATES:

We may disclose health information to our business associates who perform functions on our behalf or provide us with services, if the information is necessary for such functions or services.

RESEARCH:

Under certain circumstances, we may use and disclose health information for research purposes. 

OTHER PURPOSES:

  • We may use or disclose health information about you for other reasons:
  • In a disaster relief situation
  • To a school when proof of immunization is required for attendance, with your permission
  • When required by international, federal, state or local law, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law
  • To avert a serious threat to health or safety of the public or another person
  • For special government functions such as military, national security, and presidential protective services
  • In response to a court or administrative order, subpoena or other lawful process
  • To a law enforcement official for law enforcement purposes
  • To report child or elder abuse or neglect or domestic violence
  • If you are an inmate, to a correctional institution
  • To an organ donation bank or to facilitate organ or tissue donation
  • To workers’ compensation or similar programs for work-related injuries or illness
  • For public health activities such as to prevent or control disease, injury or disability; to report births and deaths; to notify a person who may have been exposed or who may be at risk of spreading a disease
  • To health oversight agencies for activities authorized by law
  • To a coroner/medical examiner to identify a deceased person or determine cause of death
  • To funeral directors to carry out their duties

OTHER USES OF MEDICAL INFORMATION:

Uses and disclosures of health information that are not discussed by this notice or required by law will only be made with your written permission. Your written authorization will typically be required for most uses and disclosures of psychotherapy notes, most uses and disclosures for marketing and most arrangements involving the sale of health information. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time.

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS:

If you receive alcohol or drug abuse treatment services at Woodridge Hospital, federal law and regulations provide additional privacy protection to information about these services. Generally, we may not identify that you receive services at Woodridge Hospital, or disclose any information identifying you as an alcohol or drug abuser unless:

(1) You consent in writing:

(2) The disclosure is allowed by a court order; or

(3) 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 governing the confidentiality of alcohol and drug abuse treatment records is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations governing alcohol and drug abuse treatment records do not protect:

  • Any information about a crime committed by a patient either at the treatment program or against any person who works for the program, or about any threat to commit such a crime.

  • Any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

(See 42 U.S.C. 290dd–3 and 42 U.S.C. 290ee–3 for Federal laws and 42 CFR part 2 for Federal regulations governing the privacy of alcohol and drug abuse treatment records.)

CHANGES TO THIS NOTICE:

We reserve the right to change this notice and the revised or changed notice will be effective for health 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 at each MSHA covered entity. The effective date is noted on the first page.

COMPLAINTS:

If you have questions, would like additional information or believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact our Privacy Officer in the Corporate Compliance Department at 423-302-3345 or the MSHA AlertLine at 1-800-535-9057. There will be no retaliation against you for filing a complaint.