Joint Notice of Privacy Practices
Versión en español de SRHS Aviso de prácticas de privacidad
Southern Regional Health System - Joint Notice of Privacy Practices
SOUTHERN REGIONAL HEALTH SYSTEM, INC.
THE MEDICAL STAFF OF SOUTHERN REGIONAL HEALTH SYSTEM, INC.
JOINT 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
This notice describes the privacy practices of Southern Regional Health
System (referred to as "Hospital") and the physician members
of the Hospital’s medical staff ("Physicians") related
to the use and disclosure of Protected Health Information (PHI) of its
patients. Southern Regional Health System and their Medical Staff are
covered entities that participate in an organized health care arrangement
as defined by 45 C.F.R. § 164.520(d)(1). Therefore, these entities
have elected to comply with HIPAA notice requirements by preparing a Joint
Notice ("Joint Notice") concerning our privacy practices. In
certain circumstances, however, you may also receive a separate notice
from the Hospital or Physicians.
As participants in these Privacy Practices, Hospital and Physicians are
jointly referred to hereinafter as "Participants." Participants
use confidential personal health information about patients while receiving
health care at the Hospital and maintained by Hospital, referred to below
as PHI. Participants protect the privacy of this information created or
obtained while patients are receiving health care at the Hospital and
maintained by Hospital, and PHI is also protected from disclosure by state
and federal law. In certain specific circumstances, pursuant to this Joint
Notice of Privacy Practices, patient authorization or applicable laws
and regulations, PHI can be used by Participants or disclosed to other parties.
Below are categories describing these uses and disclosures, along with
some examples to help you better understand each category.
Uses and Disclosures for Treatment, Payment and Health Care Operations
As described in detail below, Participants may use or disclose your PHI
for the purposes of treatment, payment, and health care operations, without
obtaining written authorization from you. Participants will make a good
faith effort to obtain from patients or their representatives a written
acknowledgement of receipt of this Notice, which describes the uses and
disclosures of patients' PHI.
– Participants may use and disclose PHI in the course of providing, coordinating,
or managing your medical treatment, including the disclosure of PHI for
treatment activities of another health care provider. These types of uses
and disclosures may take place between Physicians who are members of the
Hospital's medical staff, medical group practices with whom the Hospital
has entered into provider agreements, nurses, technicians, students, and
other health care professionals who provide you health care services or
are otherwise involved in your care at the Hospital. For example: while
you are a patient at the Hospital, if your attending Physician refers
you to a specialist physician, Participants may disclose your PHI to the
specialist physician with whom your attending Physician has consulted
regarding your care. While Physicians on the Hospital’s Medical
Staff are required to follow and observe these Privacy Practices, they
are independent professionals rather than employees of the Hospital, and
the Hospital expressly disclaims any responsibility for their acts or
– Participants may use and disclose PHI in order to bill and collect payment
for the health care services provided to you. For example, Participants
may need to give PHI to your insurance plan in order to be reimbursed
for the services provided to you. Participants may also disclose PHI to
its business associates, such as billing companies, claims processing
companies, and others that assist in processing health claims. Participants may also disclose PHI to other health care providers and insurance
plans for payment reasons.
For Health Care Operations – Participants may use and disclose PHI as part of its operations, including
for quality assessment and improvement, such as evaluating the treatment
and services you receive and the performance of our staff in caring for
you, provider training, underwriting activities, compliance and risk management
activities, planning and development, management and administration. Participants
may disclose PHI to doctors, nurses, technicians, students, attorneys,
consultants, accountants, and others for review and learning purposes,
to help make sure Participants are complying with all applicable laws,
and to help Participants continue to provide health care to its patients
at a high level of quality. Participants may also disclose PHI to other
health care providers and health plans for such entity's quality assessment
and improvement activities, credentialing and peer review activities,
and health care fraud and abuse detection or compliance, provided that
such entity has, or has had in the past, a relationship with the patient
who is the subject of the information.
Health Information Exchanges (HIE) – Healthcare information exchanges allow health care providers, including
Southern Regional, to share and receive information about patients, which
assists in the coordination of patient care. Southern Regional participates
in a HIE that may make your health information available to other providers,
health plans, and health care clearinghouses for treatment or payment
purposes. We may also make your health information available to other
health exchange services that request your information for coordination
of your treatment and/or payment for services rendered to you. Participation
in the HIE is voluntary, and you have the right to opt out.
Exceptions to Notice Requirement – Despite the general rules explained above, Participants may use or disclose
your PHI without providing you with this Notice to carry out treatment, payment, or health care operations in certain circumstances. For instance,
an emergency treatment situation or other circumstance may cause Participants
to be unable to provide you with this Notice prior to providing treatment,
in which case this Notice will be provided to you as soon as reasonably
practicable after such emergency treatment situation. In some cases other
persons are legally authorized to acknowledge receipt of this Notice on
behalf of a patient.
Other Uses and Disclosures for Which Authorization is not Required
In addition to using or disclosing PHI for treatment, payment and health
care operations, Participants may use and disclose PHI without your written
authorization under the following circumstances:
As Required by Law and Law Enforcement – Participants may use or disclose PHI when required to do so by applicable
law. Participants also may disclose PHI when ordered to do so in a judicial
or administrative proceeding, by a court order, to identify or locate
a suspect, fugitive, material witness, or missing person, when dealing
with gunshot and other wounds, about criminal conduct, to report a crime,
the location of a crime or victims, or the identity, description, or location
of a person who committed a crime, or for other law enforcement purposes.
For Public Health Activities and Public Health Risks – Participants may disclose PHI to government officials in charge of collecting
information about births and deaths, preventing and controlling disease,
reports of child abuse or neglect and of other victims of abuse, neglect,
or domestic violence, reactions to medications or product defects or problems,
or to notify a person who may have been exposed to a communicable disease
or may be at risk of contracting or spreading a disease or condition.
For Health Oversight Activities – Participants may disclose PHI to the government for oversight activities
authorized by law, such as audits, investigations, inspections, licensure
or disciplinary actions, and other proceedings, actions or activities
necessary for monitoring the health care system, government programs,
and compliance with civil rights laws.
Coroners, Medical Examiners, and Funeral Directors – Participants may disclose PHI to coroners, medical examiners, and funeral
directors for the purpose of identifying a decedent, determining a cause
of death, or otherwise as necessary to enable these parties to carry out
their duties consistent with applicable law.
Organ, Eye, and Tissue Donation – Participants may release PHI to organ procurement organizations to facilitate
organ, eye, and tissue donation and transplantation.
Research – Under certain circumstances, Participants may use and disclose PHI for
medical research purposes.
To Avoid a Serious Threat to Health or Safety – Participants may use and disclose PHI, to law enforcement personnel or
other appropriate persons, to prevent or lessen a serious threat to the
health or safety of a person or the public.
Specialized Government Functions – Participants may use and disclose PHI of military personnel and veterans
under certain circumstances. Participants may also disclose PHI to authorized
federal officials for intelligence, counterintelligence, and other national
security activities, and for the provision of protective services to the
President or other authorized persons or foreign heads of state or to
conduct special investigations.
Workers' Compensation – Participants may disclose PHI to comply with workers' compensation
or other similar laws. These programs provide benefits for work-related
injuries or illnesses.
Fundraising Activities – Your PHI may be used to contact you in an effort to raise money for the
Hospital. Your PHI may be disclosed to a foundation related to the Hospital.
Such disclosure would be limited to contact information, such as your
name, address, phone number, general diagnosis, and the dates you required
treatment or services at the Hospital. The money raised in connection
with these activities would be used to expand and support the Hospital’s
provision of health care and related services to the community. If you
do not want to be contacted as part of these fundraising activities, then
please notify the Hospital.
Health-related Benefits and Services; Marketing – Participants may use and disclose your PHI to inform you of treatment alternatives
or other health-related benefits and services that may be of interest
to you, such as disease management programs. Participants may use and
disclose your PHI to encourage you to purchase or use a product or service
through a face-to-face communication or by giving you a promotional gift
of nominal value.
Disclosures to You or for HIPAA Compliance Investigations – Participants may disclose your PHI to you or to your personal representative,
and is required to do so in certain circumstances described below in connection
with your rights of access to your PHI and to an accounting of certain
is disclosures of your PHI. Participants must disclose your PHI to the
Secretary of the United States Department of Health and Human Services
(the "Secretary") when requested by the Secretary in order to
investigate Participants' compliance with privacy regulations issued
under the federal Health Insurance Portability and Accountability Act
of 1996 ("HIPAA").
Inmates/Patients in Custody – Participants may disclose health information of inmates to a correctional
institution and health information of patients under custody to law enforcement
officials. This would be necessary to ensure that participants can provide
you with health care, to protect your health and safety or the health
and safety of others, or for the safety and security of the correctional
Uses and Disclosures to Which You Have an Opportunity to Object
Patient Directories – Unless you object, Hospital may use some of your PHI to maintain a directory
of individuals in its facility. This information may include your name,
your location in the facility, your general condition (e.g. fair, stable, etc.), and your religious affiliation, and the information
may be disclosed to members of the clergy. Except for your religious affiliation,
the information may be disclosed to other persons who ask for you by name.
Disclosures to Individuals Involved in Your Health Care or Payment for
Your Health Care – Unless you object, Participants may disclose your PHI to a family member,
other relative, friend, or other person you identify as involved in your
health care or payment for your health care. Participants may also notify
those people about your location or condition.
Disclosures to Insurance Plans – You have the right to restrict certain disclosures to your insurance company,
but only if you pay for the service in full and out of pocket.
Other Uses and Disclosures of PHI Which Authorization is Required
Types of situations requiring your specific authorization include the release
of psychotherapy notes, uses and disclosures of PHI for marketing purposes,
and disclosures that constitute a sale of PHI. Any other types of use
and disclosure of PHI not described above will be made only with your
written authorization, which, except in limited situations, you have the
right to revoke in writing.
Participants are required by law to maintain the privacy of your PHI, to
provide individuals with notice of its legal duties and privacy practices
with respect to PHI, and to abide by the terms described in this Notice.
Participants reserve the right to change the terms of this Notice and
of its privacy policies, and to make the new terms applicable to all PHI
it maintains. Before Participants make an important change to its privacy
policies, these entities will promptly revise this Notice and post a new
Notice in patient entrance areas of their facilities and on all maintained websites.
Your Rights Regarding Your Protected Health Information
Right to Restrict Access to Your Health Information – You may request that Participants restrict the use and disclosure of your
PHI. Participants are not required to agree to any restrictions you request,
but if they do, the participants will be bound by the agreed restrictions,
except in emergency situations.
Right to Confidential Communication – You have the right to request that communications of PHI to you from the
Participants be made by particular means or at particular locations. For
instance, you might request that communications be made at your work address,
or by e-mail rather than regular mail. Your requests must be made in writing
and sent to the Health Information Services Department. Participants will
accommodate your reasonable requests without requiring you to provide
a reason for your request.
Right to Inspect and Copy Your Health Information – Generally, you have the right to inspect and obtain a copy your PHI that
Participants maintain, provided that you make your request in writing
to the Health Information Services Department. Within thirty (30) days
of receiving your request (unless extended by an additional thirty (30)
days), Participants will inform you of the extent to which your request
has or has not been granted. In some cases, Participants may provide you
a summary of the PHI you request if you agree in advance to such a summary
and any associated fees. If you request copies of your PHI or agree to
a summary of your PHI, Participants may impose a reasonable fee to cover
copying, postage, and related costs. If Participants deny access to your
PHI, these entities will provide an explanation of the basis for denial,
as well as of your opportunity to have your request and the denial reviewed
by a licensed health care professional (who was not involved in the initial
denial decision) designated as a reviewing official. If Participants do
not maintain the PHI you request but know where that PHI is located, you
will be told how to redirect your request.
Right to Request an Amendment to Your
Records – If you believe that your PHI maintained by Participants contains an error
or needs to be updated, you have the right to request that the Participants
correct or supplement your PHI. Your request must be made in writing to
the Health Information Services Department, and it must explain why you
are requesting an amendment to your PHI. Within sixty (60) days of receiving
your request (unless extended by an additional thirty (30) days), Participants
will inform you of the extent to which your request has or has not been
granted. Participants generally can deny your request if your request
relates to PHI: (i) not created by one of the Participants; (ii) that
is not part of the records Participants maintain; (iii) that is not subject
to being inspected by you; or (iv) that is accurate and complete. If your
request is denied, Participants will provide you a written denial that
explains the reason for the denial and your rights to: (i) file a statement
disagreeing with the denial; (ii) if you do not file a statement of disagreement,
submit a request that any future disclosures of the relevant PHI be made
with a copy of your request and Participants denial attached; and (iii)
complain about the denial.
Right to Receive an Accounting of Disclosures – You generally have the right to request and receive a list of the disclosures
of your PHI that the Hospital has made at any time during the six (6)
years prior to the date of your request. (A request for a list of disclosures
made by a Physician must be made directly to that Physician's Office.)
The list will not include disclosure for which you have provided a written
authorization, and does not include certain uses and disclosures to which
this Notice already applies, such as those: (i) for treatment, payment,
and health care operations; (ii) made to you; (iii) for Hospital’s
patient directory or to persons involved in your health care; (iv) for
national security or intelligence purposes; or (v) to correctional institutions
or law enforcement officials. You should submit any such request to the
Health Information Services Department, and within sixty (60) days of
receiving your request (unless extended by an additional thirty (30) days),
Participants will respond to you regarding the status of your request.
Participants will provide the list to you at no charge, but if you make
more than one request in a year you will be charged a fee of $75.00 for
each additional request.
Right to a Copy of This Notice – You have the right to receive a paper copy of this notice upon request,
even if you have agreed to receive this notice electronically.
Right to Complain – If you believe your privacy rights with respect to your PHI have been
violated, you may complain to the Participants by contacting either the
Physician's office in question or the Compliance Office at Southern
Regional Health System and submitting a written complaint. Participants
will in no manner penalize you or retaliate against you for filing a complaint
regarding the Hospital’s privacy practices. You also have the right
to file a complaint with the Department of Health and Human Services Office
of Civil Rights.
Right to be Notified of a Breach – You have the right to be notified if we (or one of our Business Associates)
discover a breach of unsecured PHI involving your medical information.
For further information on this Joint Notice, you may contact:
Privacy Officer – 770-991-8341