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.
The Purpose and Benefit of this Notice
The purpose of this notice is to describe how medical information about you may be used and disclosed, how you can get access to this information and to inform you that the hospital shall destroy medical records after it has met all retention requirements consistent with state and federal law.
Who Will Follow This Notice
This notice describes Baptist Hospitals of Southeast Texas' ("BHSET") privacy practices, as well as the privacy practices of: (a) any health care professional authorized to enter information into your hospital chart; (b) all departments, sections 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; and (e) BHSET and all Medical Staff and Allied Health Professionals on staff at our hospitals. All of these entities, sites and locations may share medical information with each other for the treatment, payment and health care operations activities described in this notice.
Purpose of This Statement
We are required by law to maintain the privacy of your medical information. 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 at the hospital, whether made by the hospital employees or your personal physician.
This notice will tell you about the ways in which we may use and disclose medical information about you. This notice also describes your rights and certain obligations we have regarding the use and disclosure of your medical information.
We are required by law to:
- Make sure that medical information that identifies you is kept private;
- Give you this Notice of our legal duties and privacy practices with respect to your medical information; and
- Follow the terms of this notice as long as it is currently in effect. If we revise this notice, we will follow the terms of the revised notice as long as it is currently in effect.
How We May Use and Disclose Medical Information About You
The following categories (listed in bold-face print, below) describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and give you 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 on of the bold-face print categories, below.
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 BHSET. 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 services that you need, such as lab work, x-rays, and prescriptions. We also may disclose medical information about you to people outside BHSET who may be involved in your medical care after you leave the hospital, such as physicians who will provide follow-up care, physical therapy organizations, medical equipment suppliers, and skilled nursing facilities.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive at BHSET may be billed to (and payment may be collected from) your insurance company or a third party. For example, we may need to give your health plan information about surgery received at BHSET so your health plan will pay us or reimburse you for the surgery. We also may tell your health plan about treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
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 to make sure that all of out patient 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 also may disclose information to doctors, nurses, technicians, house-staff (including residents and interns), medical students, and other BHSET personnel to conduct training programs. We also may combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and certain new treatments are effective. We also may remove all information that identifies you from this set of medical information so that others may use that information to study health care and health care delivery without learning who the specific patients are.
To Business Associate for Treatment, Payment, and Health Care Operations. We may disclose medical information about you to one of our business associates in order to carry out treatment, payment, or health care operations. For example, we may disclose medical information about you to a company who bill insurance companies on the hospital’s behalf to enable that company to help us obtain payment for the health care services we provide.
Hospital Directory. Except when you express an objection when we ask you, we may include certain limited information about you in the hospital directory while you are a patient in the hospital. This information may include your name, your location in the hospital (e.g., Intensive Care Unit, Labor and Delivery, etc.), your general condition (e.g., fair, stable, etc.), and your religious affiliation. The directory information, except for your religious affiliation, also may 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 the clergy member does not ask for your name. The purpose of the Hospital Directory is to allow your family, friends, and clergy to visit you in the hospital and know how you are doing. If you cannot practicably provide your objection to these uses and disclosures because of your incapacity or an emergency treatment circumstance, we may use or disclose some or all of this information if that disclosure would be consistent with your prior expressed preference that is known to us and of the disclosure is in your best interest as determined in the exercise if out professional judgement.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a family member, other relative, or close personal friend who may be authorized by law to consent to your treatment. We also may tell your family or friends that you are in the hospital and your general condition. In addition, we may disclose medical information about you to the American Red Cross or a governmental agency or authority assisting in a disaster relief effort so that your family can be notified about you location and general condition.
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.
Treatment Alternatives. We may use and disclose medical information to give you information about treatment options or alternatives that may be of interest to you.
Fundraising Activities. We may use limited medical information about you to contact you in an effort to raise money for the Hospital and its operations. We may disclose this information to our business associates for this purpose as well. The limited medical information that would be used by the hospital or disclosed to a business associate would include demographic information about you (e.g., your name, address, phone number) and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for the Hospital's fundraising efforts, please contact BHSET Foundation at 409-212-6110.
As Required by Law. We will disclose medical information about you when required to do so by federal, state, or local law.
Public Health Activities. We may disclose medical information about you for public health activities. Public health activities generally include:
• Preventing or controlling disease, injury or disability;
• Reporting births and deaths;
• Reporting child abuse or neglect;
• Cancer Registry
• Trauma Registry
• Reporting reactions to medications or problems with products;
• Notifying people of recalls of products they may be using;
• Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• Notifying 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.
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law such as 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.
Lawsuits and Disputes. 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.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
• response to a court order, subpoena, warrant, summons or similar process;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe must be the result of criminal conduct;
• About criminal conduct we believed occurred on the premises of the Hospital;
• In emergency circumstances to report a crime; if the information related to the presence, nature of injury or illness, age, sex, and occupations of the patient who is receiving emergency medical services.
Coroners and Medical Examiners. We may release medical information about patients of the hospital to a coroner or medical examiner to identify a deceased person or to determine the cause of death.
Organ and Tissue Donation. We may release the medical information to an organization that handles organ procurement or organ, eye or tissue transplantation, or an organ bank to facilitate organ or tissue donations and transplantations.
Research. Under certain circumstances, we may use and disclose medical information about you for research projects that have been approved by an institutional review board. For example, a research project may involve comparing the health and the 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 special approval process requires an evaluation of the proposed research project and its use of medical information and balances these research needs with our patients’ needs for privacy of their medical information. Before we use or disclose medical information for research, the project generally will have been approved through this special approval process.
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 and for the health and safety of the public or another person. Any disclosure, however, would only be to a government agency or authority that is able to help prevent the threat.
Armed Forces. If you are a member of the Armed Forces, we may release medical information about you to a governmental agency or authority as required by military command authorities.
National Security and Intelligence Activities. We may release medical information about you to authorized federal officers for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose medical information about you to authorized federal officers so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations.
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, for example: (1) for the institution to provide you with health care; (2) to protect your health and safety and for the health and safety of others; or (3) for the safety and security of the correctional institution.
Workers’ Compensation. We may release medical information about you to a government agency or authority for workers’ compensation or similar programs (or as otherwise required by law). These programs provide benefits for work-related injuries or illness.
When Your Authorization is Required. Use or disclosure of your medical information for marketing purposes, as well as disclosures that constitute a sale of your medical information will only be made with your written authorization. Additionally, use or disclosure of your medical information for other purposes or activities, not listed above, will be made only with your written authorization (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 reason covered by your permission. However, we are unable to take back any disclosures we have already made with your permission.
Special Privacy Protection for Certain Types of Information. Certain types of information may be subject to additional restrictions on disclosure, such as AIDS test results and psychology notes. Alcohol and drug abuse information has special privacy protections. The Hospital will not disclose any information identifying an individual as being a patient or provide any medical treatment unless; (1) the patient consents in writing; (2) a court requires disclosure of the information; (3) medical personnel need the information to meet a medical emergency; (4) qualified personnel use the information for the purpose of conducting scientific research, management audits, financial audits, or program evaluations; (5) it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law.
You have the following rights regarding medical information we obtain about you:
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 have the right to request a restriction or limitation on medical information that we provide to your health plan, when you pay out of pocket in full for the health care item or service. 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, such as a family member or friend. For example, you could ask that we not use or disclose information about a particular surgery you have 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 with emergency treatment. To request restrictions, you must make your requests in writing. Please send your written request to the Contact Person noted under the Contact Information at the end of this notice. In your request, you must tell: (1) what information you want to limit; (2) whether you want to limit our use or disclosure of the information (or both); and (3) to whom you want the limits to apply. (e.g., disclosures to your spouse).
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 by telephone at work or that we only contact you by mail at home. To request confidential communications, you must make your request in writing. Please send your written request to the contact person noted under the contact information at the end of this notice. 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.
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; however, psychotherapy notes may not be inspected and copied. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing. Please send your written request to the contact person noted under the contact information at the end of this notice. If you request a copy of the information we may charge a fee for the cost of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, in some cases you may request that denial to 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.
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. Please send your written request to the contact person noted under the contact information at the end of this notice. 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 BHSET; (3) is not part of the information which you would be permitted to inspect and copy; or (4) is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures” from the hospital of your medical information that occurred in the past six (6) years. The accounting (or list) of disclosures will include: (1) the date of the disclosure; (2) the name of the entity or person who received the medical information and, if known, the address; (3) a brief description of the medical information disclosed; (4) a brief statement of the purpose of the disclosure (such list will not include disclosures made pursuant to an authorization or for treatment, payment, and health and healthcare operations.) To request this list, you must submit your request in writing. Please send your written request to the contact person noted under the contact information at the end of this notice. Your request must state a time period that may not be longer than six (6) years and may not include dates before April 14, 2003; however, the time period certainly may be less than six (6) years. Your request should indicate in what form you want the list (e.g., whether you want the list on paper or electronically.) The first list you request within a twelve (12) month period will be free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may chose to withdraw or modify your request at that time before any costs are incurred.
Right to be notified of a Breach. You have the right to be notified following a Breach of your unsecured medical information.
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, contact: Privacy Officer, Baptist Hospitals of Southeast Texas, P.O. Box 1591, Beaumont, Texas 77704.
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 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 hospital. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as inpatient or outpatient, we will offer you a copy of the current Notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the Federal Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint to the Hospital or the Department of Health and Human Services. All complaints to BHSET must be submitted in writing. To file a complaint with BHSET, send a written complaint to the contact information listed below.
P.O. Box 1591
Beaumont, Texas 77704
608 Strickland Drive
Orange, Texas 77630
BAPTIST HOSPITALS OF SOUTHEAST TEXAS
Privacy Officer: 409-212-5701
Compliance Officer: 409-212-6167
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS)
200 Independence Ave S.W.
Washington, D.C. 20201
OR Call Toll Free