Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. When this Notice refers to “we” or “us,” it is referring to Androscoggin Valley Hospital, AVH Surgical Associates (a department of Androscoggin Valley Hospital), Sound Medical Imaging (a department of Androscoggin Valley Hospital), and all individuals holding Medical Staff appointment and/or clinical privileges at the Hospital (some of whom may be independent contractors). These groups have agreed, as permitted by law, to share health information which was created or received while you are a patient at Androscoggin Valley Hospital, AVH Surgical Associates, or Sound Medical Imaging among themselves for purposes of treatment, payment or health care operations. This enables us to better address your health care needs. 

This Notice describes how we will use and disclose your health information. The policies outlined in this Notice apply to all of your health information generated by this organization, whether recorded in your medical record, invoices, payment forms, videotapes, or other ways. Similarly, these policies apply to the health information gathered from other organizations by any health care professional, employee, or volunteer who participates in your care.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following circumstances require an authorization from you to use or disclose your health information:

1. Uses and disclosures of protected health information for marketing purposes. “Marketing” is a communication that encourages you to purchase a product or service. However, it is not marketing if we communicate with you about health-related products or service we offer, as long as we are not paid by a third party for making that communication.

2. Disclosures that constitute a sale of protected health information.

In some circumstances we are permitted or required to use or disclose your health information without obtaining your prior authorization and without offering you the opportunity to object. These circumstances include:

1. Uses or disclosures for purposes relating to treatment, payment and health care operations. (NOTE: State laws impose further restrictions on uses and disclosures of health information relating to genetic testing and HIV/AIDS testing. As required by law, your written authorization will be requested before we use or disclose your health information related to genetic testing or HIV/AIDs even for treatment, payment or health care operations.)

A. Treatment: We may use and/or disclose your health information for the purpose of providing, or allowing others to provide, treatment to you. An example would be if your primary care physician discloses your health information to another doctor for the purposes of a consultation. Also, we may contact you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

B. Payment: We may use and/or disclose your health information for the purpose of allowing us, as well as other entities, to secure payment for the health care services provided to you. For example, we may inform your health insurance company of your diagnosis and treatment in order to assist the insurer in processing our claim for the health care services provided to you.

C. Health Care Operations: We may use and/or disclose your information for the purposes of our day-to-day operations and functions. We may also disclose your information to another covered entity, to allow it to perform its day-to-day functions, but only to the extent that we both have a relationship with you. For example, we may compile your health information, along with that of other patients, in order to allow a team of our health care professionals to review that information and make suggestions concerning how to improve the quality of care provided at this facility.

Also, we may contact you as part of our efforts to raise funds for the organization. If you do not wish to receive fundraising communications, you may contact the Privacy Officer at 603-752-2200 or by e-mail at news@avhnh.org to request a Fundraising Opt-Out Form and postage pre-paid envelope. Your request to not receive fundraising communications will become effective when we receive a completed Fundraising Opt-Out form.

2. To create material(s) that originally had any identifying information concerning you deleted from the final material(s).

3. When required by law, such as state statutes which require us to report suspected child abuse or cases of infectious disease.

4. Uses or disclosures permitted for certain national priority purposes, including:

A. For public health purposes.

B. To disclose information about victims of abuse, neglect, or domestic violence.

C. For health oversight activities, such as audits or civil, administrative, or criminal investigations.

D. For judicial or administrative proceedings when required by a court order or warrant.

E. For limited law enforcement purposes, such as the use or disclosure of health information to a correctional institution or in response to a law enforcement official’s request to assist in identifying or locating a suspect, fugitive, material witness, or missing person.

F. To assist coroners, medical examiners, or funeral directors with their official duties.

G. To facilitate organ, eye or tissue donation.

H. For certain research projects that have been evaluated and approved through a research approval process that takes into account patients’ need for privacy.

I. To avert a serious threat to health or safety.

J. For specialized governmental functions, such as military, national security, or criminal corrections purposes.

K. For workers’ compensation purposes, as permitted by law.

5. Business Associates. We may disclose your health information to our business associates who perform functions on our behalf or provide us with services if the health information is necessary for those functions or services. For example, we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your health information.

We may also use or disclose your health information in the following circumstances. However, except in emergency situations, we will inform you of our intended action prior to making any such uses and disclosures and will, at that time, offer you the opportunity to object.

1. Directories. We may maintain a directory of patients that includes your name and location within the facility, your religious designation, and information about your condition in general terms that will not communicate specific medical information about you. Except for your religion, we may disclose this information to any person who asks for you by name. We may disclose all directory information to members of the clergy.

2. Notifications. We may disclose to your relatives or close personal friends any health information that is directly related to that person’s involvement in the provision of, or payment for, your care. We may also use and disclose your health information for the purpose of locating and notifying your relatives or close personal friends of your location, general condition or death, and to organizations that are involved in those tasks during disaster situations.

Except as described above, disclosures of your health information will be made only with your written authorization. You may revoke your authorization at any time, in writing, unless we have taken action in reliance upon your prior authorization, or if you signed the authorization as a condition of obtaining insurance coverage.

YOUR RIGHTS

1. To Request Restrictions. You have the right to request restrictions on the use and disclosure of your health information for treatment, payment, or health care operations purposes or notification purposes. We are not required to agree to your request, with one exception: If you have paid out of pocket and in full for a health care item or service, you may request that we not disclose your health information related to that time or service to a health plan for purposes of payment or health care operations. If you make such a request, we will not disclose your information to the health plan unless the disclosure is otherwise required by law. If we do agree to a restriction, we will abide by that restriction unless you are in need of emergency treatment and the restricted information is needed to provide that emergency treatment. To request a restriction, submit a written request to the Contact listed on the final page of this Notice.

2. To Confidential Communications. You have the right to receive confidential communications about your own health information by alternative means or at alternative locations. This means that you may, for example, designate that we contact you only via e-mail, or at work rather than home. To request communications via alternative means or at alternative locations, you must submit a written request to the Contact listed on the final page of this Notice. All reasonable requests will be granted.

3. To Access and Copy Health Information. You have the right to inspect and copy any health information about you other than psychotherapy notes, information compiled in anticipation of or for use in civil, criminal, or administrative proceedings, or certain information that is governed by the Clinical Laboratory Improvement Act.

If your health information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your health information in the form or format you request, if it is readily producible in such form or format. If your health information is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or, if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

To arrange for access to your medical records, or to receive a copy of your medical records, you should contact the Androscoggin Valley Hospital Health Information Management Department. To arrange for access to your billing records, or to receive a copy of your billing records, you should contact the Androscoggin Valley Hospital Patient Financial Services Department or Customer Services Department. You may also submit a written request to the Contact listed on the last page of this Notice. If you request copies, you will be charged a reasonable, cost-based fee for copying the requested information.

Despite your general right to access your health information, access may be denied in some limited circumstances. For example, access may be denied if you are an inmate at a correctional institution or if you are a participant in a research program that is still in progress. Access may be denied if the federal Privacy Act applies. Access to information that was obtained from someone other than a health care provider under a promise of confidentiality can be denied if allowing you access would reasonably be likely to reveal the source of the information. The decision to deny access under these circumstances is final and not subject to review.

In addition, access may be denied if (i) access to the information in question is reasonably likely to endanger the life and physical safety of you or anyone else, (ii) the information makes reference to another person and your access would reasonably be likely to cause harm to that person, or (iii) you are the personal representative of another individual and a licensed health care professional determines that your access to the information would cause substantial harm to the patient or another individual. If access is denied for these reasons, you have the right to have the decision reviewed by a health care professional who did not participate in the original decision. If access is ultimately denied, the reasons for the denial will be provided to you in writing.

4. To Request Amendment. You may request that your health information be amended. Your request may be denied if the information in question: was not created by us (unless you show that the original source of the information is no longer available to seek amendment from), is not part of our records, is not the type of information that would be available to you for inspection or copying (for example, psychotherapy notes), or is accurate and complete. If your request to amend your health information is denied, you may submit a written statement disagreeing with the denial, which we will keep on file and distribute with all future disclosures of the information to which it relates. Requests to amend health information must be submitted in writing to the Contact listed on the final page of this notice.

5. To an Accounting of Disclosures. You have the right to an accounting of any disclosures of your health information made during the six-year period preceding the date of your request, except for: (Ii) disclosures made for the purpose of carrying out treatment, payment, or health care operations; (ii) disclosures made to you; (iii) disclosures of information maintained in our patient directory, or disclosures made to persons involved in your care, or for the purpose of notifying your family or friends about your whereabouts; (iv) disclosures for national security or intelligence purposes; (v) disclosures to correctional institutions or law enforcement officials who had you in custody at the time of disclosure; (vi) disclosures made pursuant to an authorization signed by you; (vii) disclosures that are part of a limited data set; (viii) disclosures that are incidental to another permissible use or disclosure; or (x) disclosures made to a health oversight agency or law enforcement official, but only if the agency or official asks us not to account to you for such disclosures and only for the limited period of time covered by that request. The accounting will include the date of each disclosure, the name of the entity or person who received the information and that person’s address (if known), and a brief description of the information disclosed and the purpose of the disclosure. To request an accounting of disclosures, submit a written request to the Contact listed on the final page of this Notice.

6. To a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice upon request.

7. To Receive Notice of Breach. You have the right to be notified upon a breach of any of your unsecured heath information.

OUR DUTIES

1. We are required by law to maintain the privacy of your health information and to provide you with this Notice of our legal duties and privacy practices.

2. We are required to abide by the terms of this Notice currently in effect. We reserve the right to change the terms of this Notice and to make those changes applicable to all health information that we maintain. Any changes to this Notice will be posted on our website and at our facility, and will be available from us upon request.

3. We are required to notify you in writing if we improperly use or disclose your health information in a manner that meets the definition of a “breach” under federal law. Although there are some exceptions, a breach generally occurs when health information about you is not encrypted and is accessed by, or disclosed to, an unauthorized person.

COMPLAINTS

You can complain to us and to the federal Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To lodge a complaint with us, please file a written complaint with the Contact set forth below. This Contact person will also provide you with further information about our privacy policies upon request. You will not be retaliated against for filing a complaint.

DESIGNATED CONTACT                                  

Suzanne Perkins, Privacy Officer                    

Androscoggin Valley Hospital                         

59 Page Hill Road                                        

Berlin, NH 03570                                     

603-752-2200, extension 5619

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Secretary of Health and Human Services

Hubert H. Humphrey Building

200 Independence Avenue, SW

Washington, DC 20201

Effective: August 7, 2013