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.

The Coordinated Health System of Jefferson County, Inc. is required by federal law to:

·          Maintain the privacy of your protected health information;

·          Provide you with this Notice of Privacy Practices;

·          Abide by the terms of this Notice; and

·          Change the Notice only as it states it will do.

Under Federal Privacy Regulations you have the following rights:

·          Right to request restrictions on certain uses and disclosures, though CHS is not required to agree to such restrictions.  If CHS is willing to accept such restrictions, additional statements concerning its duty to honor such restrictions and the process for terminating the restrictions will be provided.

·          Right to receive confidential communications from CHS;

·          Right to inspect and copy your own Protected Health Information;

·          Right to receive an accounting of disclosures of Protected Health Information.

·          Right to consent to uses and disclosures of your Protected Health Information for treatment, payment, and operations.

·          Right to review this Notice of Privacy Practices before signing any consent.

·          Right to authorize uses and disclosures of information for all other purposes, subject to the exceptions created by the HIPPA Privacy Standards.

·          Right to appeal denials of access to your own information to CHS except in certain circumstances.

·          Right to amend incorrect or incomplete information.  If the amendment is denied, you have a derivative right to protest the refusal to amend, as well as to require the protest to be attached to all future disclosures of the information.

·          Right to file a complaint with CHS if it fails to follow the requirements of the Privacy Standards.

·          Right to opt-out of disclosure of information to facility directories (including disclosure to clergy) or to family members or others who may be assisting with care.

·          Right to file a complaint with the Secretary of the Department of Health and Human Services if you believe privacy rights have been violated.  You should direct the complaint to:

Office for Civil Rights; Attn: Privacy

U.S. Department of Health and Human Services

200 Independence Avenue, Room 509F

Washington, D.C. 20201

e-mail address: ocrprivacy@hhs.gov

·          Right to receive a paper copy of this Notice.

CHS conducts a program entitled HealthPlus+ in cooperation with certain health care providers and other entities, including Bessemer Carraway Medical Center, Birmingham Healthcare, Carraway Methodist Medical Center, Coordinated Health System of Jefferson County Resource Center, Eastern Health System, Inc. dba: Medical Center East, Jefferson County Board of Health, the Jefferson County Medical Society, Jefferson Health Systems/Cooper Green Hospital, Montclair Baptist Medical Center, St. Vincent’s Medical Center, University of Alabama Hospital and Princeton Baptist Medical Center, the purpose of which is to reduce duplication of health and health related services in this community, to facilitate referrals for treatment and utilization of the public health clinics, to establish the concept of the Medical Home and to otherwise direct certain individuals for care in appropriate settings.  In order to perform this function, it is necessary for CHS to disclose personal, financial, and medical information and other Protected Health Information to the above and other entities.

CHS may use your Protected Health Information for or incident to your treatment or payment, or in the health operations of CHS or one or more of its affiliated entities or Business Associates.  Treatment may include activities such as your actual diagnosis, referral for primary care or subsequent referral to a specialist for specialty care, and in some cases these uses will require CHS or its affiliates to

share information obtained in rendering services to you with one or more of its affiliates.  Payment information includes financial and household income information, sources of payment, payment plan arrangements and the like and will be transmitted or shared incident to  your treatment and referral.  Business operations include information about diagnosis, treatment, payment and certain other activities, such as quality assurance review.  CHS might also share your personal health information incident to its tracking of certain physical conditions and illnesses.  Further information on your rights pursuant to this Notice of Privacy Practices can be found at 42 CFR §164.520 “Notice of Privacy Practices for Protected Health Information”.

·          For more information or to file an internal complaint, contact  the  Director of Development  at  (205) 327-8254.

·          This NPP may be amended by action of the Board of Directors of CHS in its discretion as it determines necessary.

Name of Recipient:

Date of Execution:                                                                                                        ________          

Expiration Date (if any):                          Address:                                          _______________         

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