HIPAA Notice of Privacy Practices

HIPAA 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.
If you have any questions about this notice, please call the medical center’s Privacy Officer at
278-4351.
 

I. WHO WILL FOLLOW THIS NOTICE? 

This notice describes The Niagara Falls Memorial Medical Center's practices and that of: 

A. Any health care professional authorized to enter information into your hospital chart.
B. All departments and units of the hospital;
C. Any member of a volunteer group we allow to help you while you are in the hospital.  
D. All employees, staff and other hospital personnel;
E. All satellites connected with the Niagara Falls Memorial Medical Center. All these
entities, sites and locations follow the terms of this notice. In addition, these entities, sites
and locations may share medical information with each other for treatment, payment or
hospital operations purposes described in this notice. 


II. OUR PLEDGE REGARDING MEDICAL INFORMATION 

The Niagara Falls Memorial Medical Center understands that medical information about you and
your health is personal. We are committed to protecting medical information about you. We
create a record of the care and services you receive at the hospital. We need this record 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 the hospital, whether made by hospital personnel
or your personal doctor. (Your personal doctor may have different policies or notices regarding


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the doctor's use and disclosure of your medical information created in the doctor's office or
clinic).
 
This notice will tell you about the ways in which we may use and disclose medical information
about you. We also describe your rights and certain obligations we have regarding the use and
disclosure of medical information. 

We are required by law to:
 
A. Make sure that medical information that identifies you is kept private.
B. Give you this notice of our legal duties and privacy practices with respect to medical
information.
C. Follow the terms of the notice that is currently in effect. 


III. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
 
The following categories describe different ways that we use and disclose medical 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: 

A. For Treatment: We may use medical information about you to provide you with
medical treatment or services. We may disclose medical information about you to
doctors, nurses, technicians, medical students, or other hospital personnel who are
involved in taking care of you at the hospital. For example, a doctor treating you for a
broken leg may need to know if you have diabetes because diabetes may slow the healing
process. In addition, the doctor may need to tell the dietitian if you have diabetes so that
we can arrange for appropriate meals. Different departments of the hospital also may
share medical information about you in order to coordinate the different 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 we use to provide
services that are part of your care. 
 
B. For Payment: We may use and disclose medical information about you so that the
treatment and services you receive at the hospital may 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 at the hospital 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. 

C. For Health Care Operations: We may use and disclose medical information about you
for hospital operations. These uses and disclosures are necessary to run the hospital and

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make sure that all of our patients receive quality care. For example, we may use medical
information to review our treatment and services and to evaluate the performance of our
staff in caring for you. We may also combine medical information about many hospital
patients to decide what additional services the hospital should offer, what services are not
needed, and whether certain new treatments are effective. We may also disclose
information to doctors, nurses, technicians, medical students, and other hospital personnel
for review and learning purposes. We may also combine the medical information we have
with medical information from other hospitals 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 health care and health care delivery without learning who the specific patients
are. 

D. Appointment Reminders: We may use and disclose medical information to contact you
as a reminder that you have an appointment for treatment or medical care at the hospital. 

E. Treatment Alternatives: We may use and disclose medical information to tell you about
or recommend possible treatment options or alternatives that may be of interest to you. 

F. Health-Related Benefits and Services: We may use and disclose medical information to
tell you about health-related benefits or services that may be of interest to you. 

G. Fundraising Activities: We may use medical information about you to contact you in an
effort to raise money for the hospital and its operations. We may disclose medical
information to a foundation related to the hospital so that the foundation may contact you
in raising money for the hospital. We only would release contact information, such as
your name, address and phone number and the dates you received treatment or services at
the hospital. If you do not want the hospital to contact you for fundraising efforts, you
must notify the NFMMC Foundation in writing at 278-4604. 

H. Hospital Directory: We may include certain limited information about you in the
hospital directory while you are a patient at the hospital. This information may include
your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and
your religious affiliation. The directory information, except for your religious affiliation,
may also be released to people who ask for you by name. 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. This is so your family, friends and clergy can visit you in the hospital and
generally know how you are doing. You have the opportunity to object to having your
information in the patient directory. 

I. Individuals Involved in Your Care or Payment for Your Care: We may release
medical information about you to a friend or family member who is involved in your
medical care. We may also give information to someone who helps pay for your care. We
may also tell your family or friends your 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

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location. You have the opportunity to object to having your medical information released
to a friend or family member who is involved in your medical care. 

J. Marketing: We may give you information that would encourage you to purchase or use a
product that the hospital is currently using. We do not have to obtain your authorization if
we are giving you a promotional gift of nominal value. If the promotional gift were to
involve a direct or indirect payment to Niagara Falls Memorial Medical Center from a
third party, we must obtain your authorization that would state such payment is involved.
We do not need to obtain your authorization if we are communicating to you face to face. 

K. Research: Under certain circumstances, we may use and disclose medical information
about you for research purposes. We may use medical information about you for use in
healthcare operations. This research would be done to improve health or reduce health
care costs for patients. 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, however, are subject to a special approval
process. This process evaluates a proposed research project and its use of medical
information, trying to balance the research needs with patients' need for privacy of their
medical information. Before we use or disclose medical information for research, the
project will have been approved through this research approval process. We may,
however, disclose medical information about you to people preparing to conduct a
research project, for example, to help them look for patients with specific medical needs,
so long as the medical information they review does not leave the hospital. We will
almost always ask for your specific permission if the researcher will have access to your
name, address or other information that reveals who you are, or will be involved in your
care at the hospital. 

L. Psychotherapy Notes: We may use such medical information in our training program for
students, trainees, or practitioners that are learning under supervision to practice or
improve their skills in group, joint, family or individual counseling. This medical
information may be used by the originator for treatment. The Niagara Falls Memorial
Medical Center may use this information to defend itself in a legal action or other
proceeding brought on by the patient. In all other cases, we would have to obtain your
authorization for use of this medical information. 

M. As Required by Law: We will disclose medical information about you when required to
do so by federal, state or local law. 

N. To Avert a Serious Threat to Health or Safety: We may use and disclose medical
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. Any disclosure, however,
would only be to someone able to help prevent the threat. 


IV. SPECIAL SITUATIONS 


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A. Organ and Tissue Donation: If you are an organ donor, we may release medical
information to organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ donation bank, as necessary to facilitate organ or tissue
donation and transplantation. 

B. Military and Veterans: If you are a member of the armed forces, we may release
medical information about you as required by military command authorities. We may
also release medical information about foreign military personnel to the appropriate
foreign military authority. 

C. Workers' Compensation: We may release medical information about you for workers'
compensation or similar programs. These programs provide benefits for work-related
injuries or illness. 

D. Public Health Risks: We may disclose medical information about you for public health
activities. These activities generally include the following:
 
1. To prevent or control disease, injury or disability;
2. To report births and deaths;
3. To report child abuse or neglect;
4. To report reactions to medications or problems with products;
5. To notify people of recalls of products they may be using;
6. 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;
7. To notify the appropriate government authority if we believe a patient has been
the victim of abuse, neglect or domestic violence. We will only make this
disclosure if you agree or when required or authorized by law. 

E. Health Oversight Activities: We may disclose medical information to a health oversight
agency for activities authorized by law. These oversight activities include, for example,
audits, investigations, inspections, and licensure. These activities are necessary for the
government to monitor the health care system, government programs, and compliance
with civil rights laws. 

F. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose
medical information about you in response to a court or administrative order. We may
also disclose medical information about you in response to a subpoena, discovery request,
or other lawful process by someone else involved in the dispute, but only if efforts have
been made to tell you about the request or to obtain an order protecting the information
requested. 

G. Law Enforcement: We may release medical information if asked to do so by a law
enforcement official:
1. In response to a court order, subpoena, warrant, summons or similar process;
2. To identify or locate a suspect, fugitive, material witness, or missing person; 

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3. About the victim of a crime if, under certain limited circumstances, we are unable
to obtain the person's agreement;
4. About a death we believe may be the result of criminal conduct;
5. About criminal conduct at the hospital; and
6. 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. 

H. Emergency Circumstances: We may release medical information about you if the
opportunity to object cannot be provided because of incapacity or if there is a need for
emergency treatment. We may disclose some or all of your personal health information
for the facility's directory based on previous preferences that were expressed by you. We
may also disclose some or all of your personal health information if it is in your best
interest, which would be determined by the Niagara Falls Memorial Medical Center in
the exercise of professional judgment. 

I. Coroners, Medical Examiners and Funeral Directors: We may release medical
information to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death. We may also release medical
information about patients of the hospital to funeral directors as necessary to carry out
their duties.
 
J. National Security and Intelligence Activities: We may release medical information
about you to authorized federal officials for intelligence, counterintelligence and other
national security activities authorized by law. 

K. Protective Services for the President and Others: We may disclose medical
information about you to authorized federal officials so they may provide protection to
the President, other authorized persons or foreign heads of state or conduct special
investigations. 

L. L. Inmates: If you are an inmate of a correctional institution or under the custody of a
law enforcement official, we may release medical information about you to the
correctional institution or law enforcement official. This release would be necessary (1)
for the institution to provide you with health care; (2) to protect your health and safety or
the health and safety of others; or (3) for the safety and security of the correctional
institution. 


V. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
 
You have the following rights regarding medical information we maintain about you: 

A. Right to Inspect and Copy: You have the right to inspect and copy 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. 

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To inspect and copy medical information that may be used to make decisions about you,
you must submit your request in writing. This request must in writing to the Health
Information Management Department. 

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 will respond to your request
within 10 business days from the date of the receipt of the request. 

We may deny your request to inspect and copy in certain very limited circumstances. If
you are denied access to medical information, you may request that the denial be
reviewed. Another licensed health care 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. 

B. 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 the hospital. 

To request an amendment, your request must be made in writing and submitted to the
Health Information Management Department. 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:
 
1. Was not created by us, unless the person or entity that created the information is
no longer available to make the amendment;
2. Is not part of the medical information kept by or for the hospital;
3. Is not part of the information which you would be permitted to inspect and copy;
4. Is accurate and complete. 

If your request is granted, Niagara Falls Memorial Medical Center will make the
amendment and inform you when it is completed. If your request is denied, we will
provide you with a written denial stating the basis for the denial. You have the right to
submit a written statement disagreeing with the denial. The Niagara Falls Memorial
Medical Center must act on a request no later than 60 days after receipt of the request. 

C. Right to an Accounting of Disclosures: You have the right to request an "accounting of
disclosures." This is a list of the disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing.
The request must be submitted to the Health Information Management Department. Your
request must state a time period which may not be longer than six years and may not
include dates before Feb. 26, 2003. 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. We

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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. 

D. Right to Request Restrictions: You have the right to request a restriction or limitation
on the medical information we use or disclose about you for treatment, payment or health
care operations. You also have the right to request a limit on the medical 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. 

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 emergency treatment. 

To request restrictions, you must make your request in writing. This request must be in
writing to the Health Information Management Department. 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 spouse. 

E. Right to Revoke Authorization: You have the right to revoke your authorization at any
time provided it is in writing. 

F. Right to Request 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 only contact you at work or by mail. 

To request confidential communications, you must make your request in writing to
Health Information Management. We will not ask you the reason for your request. 

We will accommodate all reasonable requests. Your request must specify how or where
you wish to be contacted. 

G. 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. To
obtain a paper copy of this notice, contact: 

Patient Access Services at 278-4474
Health Information Management at 278-4328
Privacy Officer at 278-4351
 
VI. CHANGES TO THIS NOTICE 

A. We reserve the right to change this notice. 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 the

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hospital. The notice will contain, on the first page, the effective date. In addition, each
time you register at or are admitted to the hospital for treatment or health care services as
an inpatient or outpatient, we will offer you a copy of the current notice in effect. 


VII. COMPLAINTS 

If you believe your privacy rights have been violated, you may file a complaint with the hospital
or with the Secretary of the Department of Health and Human Services. To file a complaint with
the hospital, contact the Privacy Officer at 278-4351. 

You may also contact the Secretary of the Department of Health and Human Services at 200
Independence Avenue, South West, Washington, D. C. 20201. You may also reach the
Department of Health and Human Services toll free by dialing 1-877-696-6775. 

All complaints must be submitted in writing. You will not be penalized for filing a complaint. 


VIII. OTHER USES OF MEDICAL INFORMATION 

Other uses and disclosures of medical 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 medical 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 medical 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. 


IX. EFFECTIVE DATE OF THIS NOTICE: 

This notice went into effect on April 14, 2003.