We are committed to serving you.
At HealthLinc, your rights and privacy are a top priority.
Patient Bill of Rights
As a Patient, You Have the Right:
- To be treated with dignity and respect.
- To be provided assistance in a prompt, courteous and responsible manner.
- To complete privacy and confidentiality.
- To information regarding your diagnosis, evaluation, treatments
andprospects for recovery in terms you can understand.
- To understand the medications prescribed for you, what they are, what they are for, how to take them properly and what the possible side effects are.
- To be informed of the costs associated with your treatment upon request.
- To participate in decisions involving your health care, including, but not limited to choosing your healthcare provider and receiving information about any proposed treatment or procedure in order to give informed consent.
- To know the names, titles
andqualifications of all who provide your care.
- To be informed of the procedure for submitting a complaint about HealthLinc, Your Community Health Center, and/or the quality of care you have received and to receive a response to your complaint in a timely manner.
- To initiate the grievance procedure without fear of reprisal; which includes the right to a fair hearing, if you are not satisfied with HealthLinc’s decision regarding any complaint.
- To review and obtain a copy of your medical record, subject to state law and HealthLinc’s policies and procedures.
- To participate in the development of your plan of care in a language you can understand and
tohave a designated representative involved.
- To reasonable access to care within HealthLinc’s scope of services, its stated mission
andapplicable laws and regulations.
- To refuse treatment to the extent permitted by law.
- To participate in the consideration of ethical issues that arise in your care.
- To be informed of medical consequences and risks of your decision to refuse treatment.
- To formulate an Advanced Directive or Living Will.
- To designate a surrogate
decision maker, such as your guardian, next of kin, or legally authorized responsible person.
- To care which takes into consideration your psychosocial, spiritual, and cultural values.
- To appropriate assessment and management of pain.
- To access to emergency healthcare services.
As a Patient, You Have the Responsibility:
- To know the benefits and exclusions of your health plan coverage.
- To respect the rights, property
andenvironment of all HealthLinc healthcare providers, employees, and patients.
- To provide HealthLinc with complete and accurate information about all present and past health matters and report all changes in your condition.
- To clearly understand a prescribed course of treatment and comply with the treatment plan agreed upon by you and your physician.
- To keep your appointments and, if unable to do so, to notify the office as soon as possible, so that your appointment time can be given to another patient.
- To pay all applicable co-payments at the time of service.
- To express your opinions, concerns or complaints in a constructive manner to the appropriate people.
- To remember to notify HealthLinc in a timely manner of changes in family size, address, phone number or third- party payment (including Medicaid and Medicare) company status.
- To cooperate with all persons providing your care and treatment.
- To try to understand and follow instructions concerning your treatment and ask questions if you do not understand or need an explanation.
- To be responsible in your payment for treatment and to be cooperative and timely in providing insurance and eligibility information.
- To accept responsibility for consequences if you decide to refuse treatment or ignore instructions.
- To provide proof of identity and/or income when requested to do so.
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.
If you have any questions about this Notice, please contact HealthLinc’s Privacy Officer, Melissa Mitchell,
WHO WILL FOLLOW THE PRIVACY PRACTICES DESCRIBED IN THIS NOTICE
This Notice of Privacy Practices (Notice) describes the privacy practices of HealthLinc (the Center) and its workforce members (including employees, contractors, physicians, nurses, other licensed or certified personnel, volunteers, and front desk, billing and administrative personnel) who have a need to use your health information to perform their jobs. It also applies to any individuals authorized to enter information into your Center record. Your other healthcare providers may have different policies regarding their use and disclosure of your health information created at their location.
ABOUT YOUR HEALTH INFORMATION
We understand that health information about you and your health is personal, and protecting your health information is important to us. We create a record of the care and services you receive at the Center. 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 Center, whether made by Center personnel or other health care providers, whether stored and transmitted electronically or by other means. We are required by law to:
- Maintain the privacy of health information that identifies you (with certain exceptions);
- Give you this Notice of our legal duties and privacy practices with respect to health information we collect and maintain about you; and
- Follow the terms of this Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that we may use and disclose health information. Following each category is an explanation. 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.
- Disclosure at Your Request. We may disclose health information when requested by you. This disclosure at your request may require a written Authorization by you.
- For Treatment. We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, students, or other Center personnel who are involved in taking care of you at the Center. 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. Additionally, the doctor may need to tell the social worker if you have diabetes so we can arrange for appropriate follow up. Different areas of the Center also may share health information about you in order to coordinate the different care you need, such as medications, lab work and x-rays. We also may disclose health information about you to people outside the Center who may be involved in your healthcare after you leave the Center, such as nurses, social workers, family members, or clergy. We may also use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
- For Payment. We may use and disclose health information about you so that the treatment and services you receive at the Center may be billed to and payment may be collected from you, an insurance company or a third party such as Workers Compensation. For example, we may need to give your health plan information about a procedure you received at the Center so your health plan will pay us or reimburse you for the procedure or encounter. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your health plan will cover the treatment.
- For Health Care Operations. We may use and disclose health information about you for our health care operations activities. These uses and disclosures are necessary to operate the Center efficiently and make sure that all of our patients receive quality care. For example, we may use health information to review the safety and the quality our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine and analyze health information about many Center patients to decide what additional services the Center should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, students, volunteers and other Center personnel for review and learning purposes. Additionally, we may combine the health information we have with health information from other Centers to compare how we are doing and to see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are.
ADDITIONAL USES AND DISCLOSURES OF HEALTH INFORMATION:
- As Required by Law. We will disclose health information about you when required to do so by federal, state or local laws or regulations.
- Sign-in Sheet. We may use and disclose health information about you by having you sign in when you arrive at the Center. We may also call out your name when you are ready to be seen.
- Appointment And Patient Recall Reminders. We may use and disclose your health information to contact you to remind you regarding appointments or for health care that you are to receive.
- Business Associates. Some of our functions are accomplished through contracted services provided by Business Associates. A Business Associate may include any individual or entity that receives your health information from us in the course of performing services for the Center. Such services may include, without limitation, legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation or financial services. When these services are contracted, we may disclose your health information to our Business Associates so that they can perform the job we have asked them to do. To protect your health information, however, we require the Business Associate to appropriately safeguard your information.
- Disaster Relief. We may disclose information about you to an entity assisting in disaster relief so that your family can be notified about your condition, status and location.
- Health-Related Products and Services. We may use and disclose health information to tell you about our health-related products or services that may be of interest to you.
- Family, Friends, or Other Individuals Involved in your Care or Payment for Your Care. We may disclose your health information to notify or assist in notifying a family member, your personal representative, or another individual involved in or responsible for your health care about your location at the Center, your general condition, or in the event of your death. We may also disclose information to someone who helps arrange for payment for your care. If you are able and available to agree or to object, we will give you the opportunity to agree or object prior to making these disclosures, although we may disclose this information in the case of a disaster even over your objection if we believe it is necessary to respond to the disaster or emergency situation. If you are unable or unavailable to agree or object, we will use our best judgment in any communication with your family, personal representative, and other involved individuals.
- Research. Under certain circumstances, we may use and disclose health information about you for research purposes. 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 health information, trying to balance the research needs with patients’ need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process. However, we may also disclose health 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 health information they review does not leave the Center.
- To Avert a Serious Threat to Health or Safety. We may use and disclose health 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. For example, we may notify emergency response personnel about a possible exposure to Acquired Immune Deficiency Syndrome (AIDS) and/or the Human Immunodeficiency Virus (HIV). Any such disclosure, however, would only be to the extent required or permitted by federal, state or local laws and regulations.
- Change of Ownership. In the event that the Center is sold or merged with another organization, your health information/medical record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another Center, medical group, physician or other healthcare provider.
- Funeral Directors, Coroners and Medical Examiners. We may disclose your health information to funeral directors as necessary to carry out their duties. We may also disclose health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
- Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by federal, state or local laws and regulations. These oversight activities include, for example, audits, inspections, licensure reviews, investigations into illegal conduct, compliance with other laws and regulations. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the institution or law enforcement official, if the disclosure is necessary (a) for the institution to provide you with health care; (b) to protect your health and safety or the health and safety of others; or (c) for the safety and security of the correctional institution.
- Law Enforcement. We may release your health information if asked to do so by a law enforcement official in the following circumstances: (a) in response to a court order, subpoena, warrant, summons or similar process; (b) to identify or locate a suspect fugitive, material witness, or missing person; (c) about the victim of a crime, if, under certain limited circumstances, we are unable to obtain the person’s agreement; (d) about a death we believe may be the result of criminal conduct; (e) about criminal conduct at the Center; or (f) in emergency situations to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
- Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your health information to the extent expressly authorized by a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if reasonable efforts have been made to notify you of the request (which may include written notice to you) and you have not objected, or to obtain an order protecting the information requested.
- Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
- National Security and Intelligence Activities. We may release health information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.
- Organ and Tissue Procurement Organizations. If you are an organ donor, we may disclose health 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.
- Protective Services for the President and Others. We may disclose health information about you to authorize federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or to conduct special investigations.
- Public Health Reporting. We may disclose health information about you for public health activities. We will only make this disclosure if you agree or when required or authorized by law. These activities generally include the following: (a) to prevent or control disease, injury or disability; (b) to report births and deaths; (c) to report the abuse or neglect of children, elders and dependent adults; (d) to report reactions to medications or problems with products; (e) to notify people of recalls of products they may be using; and (f) 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.
- Victims of Abuse, Neglect or Domestic Violence. We may disclose your health information to notify the appropriate government authority if we believe that a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure when required or authorized by law. Indiana Code 31-33, 35-46.
- Workers’ Compensation. We may disclose health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- Security Clearances. We may use medical information about you to make decisions regarding your medical suitability for a security clearance or service abroad. We may also release your medical suitability determination to the officials in the Department of State who need access to that information for these purposes.
- Multidisciplinary Personnel Teams. We may disclose health information to a state or local government agency or a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.
- Special Categories of Health Information. In some circumstances, your health information may be subject to additional restrictions that may limit or preclude some uses or disclosures described in this Notice or Privacy Practices. For example, there are special restrictions on the use and/or disclosure of certain categories of health information such as: (a) AIDS treatment information and HIV tests results; (b) treatment for mental health conditions and psychotherapy notes; (c) alcohol, drug abuse and chemical dependency treatment information; and/or (d) genetic information, are all subject to special restrictions. In addition, Government health benefit programs, such as Medicare or Medicaid, may also limit the disclosure of patient information for purposes unrelated to the program.
YOUR PRIVACY RIGHTS
You have the following rights regarding health information we maintain about you:
- Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. Usually this includes medical and billing records, but may not include some mental health information. If you request a copy of your health information that may be used to make decisions about your care, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to:
2401 Valley Drive
Valparaiso, IN 46383
Attention: Melissa Mitchell, Privacy Officer
We may deny your request to inspect and copy in specific circumstances. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Center will review your request and the denial. The person conducting the review will not be the person who denied your request. The Center will comply with the outcome of the review.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the health information the Center uses or discloses about you for treatment, payment or health care operations. You can also request a restriction or limitation on the health 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 reserve the right to accept or reject your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. We will notify you if we do not agree to a requested restriction. To request restrictions, you must submit a written request to the Center at the above address. In your request, you must state: (a) what information you want to limit; (b) whether you want to limit its use, disclosure or both; and (c) to whom you want the limits to apply; for example, no disclosures to your spouse.
- Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your health information to a health plan if the health information pertains to health care services for which you paid in full directly to the Center and the disclosure is not otherwise required by law.
- Right to Amend. If you feel that health 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 to your health information for as long as the information is kept by or for the Center. You must make your request to amend your health information, in writing, and submit it to the Center at the above address. You must include a reason that supports your request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the health information kept by or for the Center;
- Is not part or the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
The law permits us to deny your request for an amendment if it is not in writing or does not include a reason to support the request.
Even if the Center denies your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your medical record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.
- Request an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” Such an accounting is a list of the disclosures we made of health information about you other than our own uses for treatment, payment and health care operations (as those functions are described above) and with other expectations pursuant to law. To request this list or accounting of disclosures, you must submit your request in writing to the Center at the above address. Your request must state a time period that may not be longer than six (6) years. Your request should indicate in what form you want the list (for example, on paper or electronically). 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 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.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about health 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. You must make your request for confidential communications in writing to the Center at the address noted above. 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 Obtain a Paper Copy of this Notice. You have the right to receive a paper copy of this Notice. You may request 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.
- Right to Notice of Breach. You have the right to be notified if we or one of our Business Associates becomes aware of an improper disclosure of your health information.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. We reserve the right to make the revised or changed Notice effective for all health information we have about you as well as any information we receive in the future. We will post a copy of the current Notice in the Center. The Notice will contain the effective date on the first page, in the top right-hand corner. If we amend this Notice, we will offer you a copy of the current Notice in effect. You may request a copy of the current Notice each time that you visit the Center for services or by calling the Center and requesting that the current Notice be sent to you in the mail.
FOR MORE INFORMATION, TO FILE A COMPLAINT OR TO REPORT A PROBLEM
If you believe that your privacy rights have been violated, please let us know promptly so we can address the situation. You may file a complaint with the Center and/or with the Secretary of the federal Department of Health and Human Services. All complaints must be submitted in writing.
To file a complaint with the Center, send a written complaint to the Center’s Privacy Officer at:
2401 Valley Drive
Valparaiso, IN 46383
Attention: Melissa Mitchell, Privacy Officer
If you would like to discuss a problem without submitting a formal complaint, you may contact HealthLinc’s Privacy Officer, Melissa Mitchell, by telephone at (219) 465-9503; or by facsimile at (219) 462-9507; or via e-mail at: email@example.com. In addition, you may contact the Chief Executive Officer, Beth Wrobel, by telephone at (219) 465-9500; or by facsimile at (219) 462-9507; or via e-mail at: firstname.lastname@example.org.
You will not be penalized for filing a complaint.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health 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 health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will stop the uses and disclosures allowed by that permission, except to the extent that we have already acted in reliance on your permission. For example, we are unable to take back any disclosures we have already made with your permission.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE
We will ask you to sign an acknowledgment that you received this Notice.
This notice is effective July 22, 2014.