Who Will Follow This Notice?
This notice describes the privacy practices of Gaylord Hospital, Gaylord Farms Rehabilitation Center, related entities and their respective facilities and programs, including its facilities located throughout Connecticut (collectively, “Gaylord”). This Joint Notice applies to Gaylord Inpatient or Outpatient or any other service provided to you in a Gaylord-affiliated program involving the use or disclosure of your protected health information (PHI). The privacy practices described in this Notice will also be followed by:
• Physicians who are members of Gaylord’s medical staff or who practice at its facilities;
• All employees, trainees, students or volunteers at any of Gaylord’s locations;
• Any health care professional who treats you at any of Gaylord’s locations;
• Business associates or partners who have access to health information, because of the work they do with us.
In addition, these people, entities, sites, and locations may share information as necessary to coordinate your care and for the purposes described in this Notice. While the entities and health professionals listed above engage in many joint activities and provide services in a clinically integrated care setting, many of them constitute separate legal entities.
What Is the Purpose of this Notice?
This Notice of Privacy tells you how we may use and disclose your PHI that deals with your Treatment, Payment or Health Care Operations (TPO), or for other lawful purposes and your rights regarding your medical information. This Notice applies to uses and disclosures that we may make of all your health information whether created or received by us. It extends to information received or created by our employees, staff, and volunteers as well as by doctors and other health care practitioners practicing at the Hospital.
How Will We Share This Notice?
We will post a current notice in prominent locations throughout our facilities, on our website, and offer this Notice to all our patients. You may ask to receive a paper or electronic copy of this Notice. We may be ask you to sign a form stating you were offered this notice. We reserve the right to change the terms of this Notice from time to time without notice to you, which will apply to all your health information we then have about you, and information we receive in the future. The new notice will be available upon request, posted throughout our facility and on our website.
What is Protected Health Information, Use, Disclosure and Authorization?
Protected Health Information, or PHI, is information about you that may identify you; relate to your past, present or future health condition; was obtained when you received services at Gaylord; or was received from other providers (doctors, hospitals, etc.). This information is created, stored, and may be transmitted by verbal, electronic and/or written means. Gaylord must often share your information for treatment, payment, healthcare operations and other purposes as described in this Notice. We will strive to do this in a safe, secure and responsible manner.
Use means the sharing, utilization or examination of information by individuals within our practice.
Disclose means to release, transfer, or divulgence of information by us to individuals outside our practice.
Authorization means your written permission as to a particular type of release of your information to you, another person, or an organization.
How we Use and Disclose your Protected Health Information
The following categories describe some of the ways that we may use or disclose your PHI without your prior authorization:
* For treatment purposes by physicians, therapists, nurses and other healthcare team members to treat you. For example, if you receive Inpatient services, we will automatically forward a copy of your report to the physician that referred you to us.
* For payment of your healthcare bills by Billing, Benefits and other support staff to get payment from health plans or other entities. For example, we will access your PHI from the hospital transferring you to us for inpatient services so that we may approve your admission and payment for services by your insurance company; we may supply your insurance company with a complete copy of your medical record from your hospital stay.
You may request that information for a specific service or health care item not be shared with your health insurer for the purpose of payment or our operations if you pay for the service or item out-of pocket in full prior to receiving the treatment or item. We will honor your request unless the law requires us to share that information.
* To support healthcare operations by clinical and support staff to run our hospital, improve your care and contact you when necessary. For example, teaching therapy and/or nursing students; or for quality improvement activities.
Subject to certain requirements your PHI may be released to various agencies or for specific
Public Health Activities
We may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention. We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure/accreditation/state and other surveyors, disciplinary actions review, administrative and/or legal proceedings and to quality oversight agencies.
Abuse or Neglect Reporting
In accordance with federal and/or state law, we may disclose your medical information when it concerns abuse, neglect or violence to you.
We may disclose your medical information in the course of certain judicial or administrative proceedings.
We may disclose your medical information for law enforcement purposes, military reporting or other specialized governmental functions.
Coroners, Medical Examiners and Funeral Directors
We may disclose your medical information to a coroner, medical examiner or a funeral director.
Organ and Tissue Donation
If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization.
We may disclose your medical information for certain research purposes. For example, we may share daily patient admission criteria, such as diagnoses and date of birth, with a researcher to identify potential candidates for involvement in a research study. All research projects are subject to a special approval process that includes assurances for protecting our patient’s health information.
In the event of a disaster, we may share PHI with disaster relief authorities so your family can be notified of your location and condition.
We may disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or to the public.
We may disclose your medical information as authorized by laws relating to workers' compensation or similar programs.
Business Associates who help provide services to us in order to treat you may receive your PHI. For example, we may contract with accrediting agencies, management consultants, quality assurance reviewers, billing and collection companies and accountants to provide services on our behalf. We require all business associates to sign a written agreement which requires that they protect and safeguard your health information.
There are other ways we may use or disclose your PHI:
∗ If you are seen for Outpatient or Sleep Medicine services and need to return for another visit, we may help you remember the next visit by mailing you an appointment reminder to the address you give us. If you missed an appointment we may call you to reschedule, and may leave a general (voice mail) message if you are not available.
∗ We may contact you to talk about different ways of treating your condition so that you and your provider (doctor, nurse, physical therapist, etc.) can decide what will be most helpful.
∗ We may contact you to talk about services we offer that may improve your health condition. For example, we may refer you to one of our support groups while you are receiving care or after services are rendered.
∗ We may collect information at Registration such as a copy of your Drivers License, to validate your identity.
∗ We may share information with individuals involved with paying for your healthcare services/treatments.
∗ We may share information with parents, guardians and/or others with legal responsibilities for minors, conservators and those holding power of attorney for patients unable to make healthcare decisions on their own. In addition, those persons may exercise the rights described in this Notice on behalf of such patients.
∗ Unless you specifically tell us in advance not to do so, we may share health information about you to a family member or friend involved with your medical care.
∗ We may include limited information to be listed in the hospital directory, if you are admitted. This directory is used to locate patients to receive visitors, phone calls, mail, flowers, etc. You may chose to remove your name from this directory when you register for inpatient services or anytime during your hospital stay.
∗ In response to specific requests for information by friends, the media, etc., we will provide only a one-word description of your general condition (good, fair, etc.) and your location within the hospital. Persons seeking information must tell us your full name.
∗ We may use certain information, such as your address, to contact you in the future about your possible interest in contributing to Gaylord Hospital. Money raised is used to expand and improve the services and programs we provide to the community. You can request not to be contacted for fundraising or marketing activities by notifying us when you schedule your visit or during registration. You may also contact the Privacy Officer at any time to discuss or change your preference to be contacted.
∗ With your permission, we may collect your Social Security number in the course of business. We protect the confidentiality of the Social Security numbers we collect by limiting access, prohibiting unlawful disclosure; reviewing our processes to protect this information on a regular basis, training staff on proper handling of this information and requiring other persons that we use for business purposes to protect your information.
The above examples do not include all the ways Gaylord may use or disclose your protected health information.
Special Rules for Disclosure of Psychiatric, Substance Abuse and HIV-Related Information
For disclosures concerning protected health information relating to care for psychiatric conditions, substance abuse or HIV related testing and treatment, special restrictions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special Authorization or a court orders the disclosure.
We will not disclose records we may have relating to a diagnosis or treatment of a mental condition, or which are prepared at a mental health facility, without specific written Authorization from you or as required or permitted by law.
HIV related information: We will disclose HIV related information only as permitted or required by Connecticut law, unless we have received your specific written Authorization. A general authorization for release of medical or other information will not be sufficient for purposes of releasing HIV-related information. As required by Connecticut law, if we make a lawful disclosure of HIV-related information, we will enclose a statement that notifies the recipient of the information that they are prohibited from further disclosing the information.
Substance abuse treatment information: If we have information about treatment in a specialized substance abuse program, your specific written Authorization will be needed for certain disclosures, except in cases of emergencies, certain reporting requirements and other disclosures specifically allowed under Federal law.
Use and Disclosure of PHI Based on Your Written Authorization
In instances in which we are not permitted to use or disclose your PHI without your authorization, your health information will not be used or disclosed to others unless you give us a written authorization. You may cancel this authorization at any time, but your cancellation will not affect uses or disclosures that we already made in response to that authorization. Requests to cancel an authorization must be in writing and sent to the Gaylord Hospital’s Privacy Officer.
A specific authorization is required for the release of information further protected by state and federal confidentiality laws and includes mental health, HIV/AIDS, alcohol, and drug information.
Your Rights Regarding Your Medical Information. You May:
* Request to see or get a copy of your medical record and health information we use to make decisions about your care in either paper or electronic format. We will provide you a copy or a summary of your health information within 30 days of your request. If a request is denied, you have a right to appeal that decision. You may be charged a reasonable fee for copies of or to view your record.
* Request that we correct (amend) your health information if you believe it contains wrong information or if you believe information is missing. We may deny your request under certain circumstances and we will explain why in writing within 60 days of your request. You have the right to respond to our denial with a written statement. . .
* Request an accounting (list) of when we released your medical information in response to state, Federal or local laws for the six years prior to the date or your request. We will provide you with who we shared it with and why. This listing does not include disclosures for treatment, payment, healthcare operations, and requests you gave us written authorization to release you gave us in writing to release your information, are not included in this listing. You may be charged a reasonable fee for copies of this information.
∗ Request that your medical information be communicated to you in a confidential manner by using a mailing address that is different from your home address or a telephone number that is different from your home phone number.
∗ Request that we not use or disclose medical information about you to persons involved in your care except when required by law or in an emergency.
* Request restrictions on use and disclosure of your personal health information for treatment, payment and healthcare operations. If Gaylord agrees to a reasonable restriction, we will comply with your request. However, we do not have to agree to a requested restriction.
* We will notify you promptly if a breach occurs that may have comprised the privacy and security of your health information.
To exercise any of your rights, you may submit a request when you register for services, during your hospital stay or submit a letter to Gaylord’s Privacy Officer.
How to File a Complaint
If you believe your privacy rights have been violated, you have the right to file a compliant with Gaylord Hospital and/or the Department of Health and Human Services, Office of Civil Rights, by submitting a letter. There will be no penalty or retaliation against you or any individual for filing a complaint.
Who to Contact:
P.O. Box 400
Gaylord Farms Road
Wallingford, CT 06492
Office for Civil Rights
U.S. Department of Health and Human Services
J. F. Kennedy Federal Building – Room 1875
Boston, Massachusetts 02203
Phone: (617) 565-1340
FAX: (617) 565-3809
TDD: (617) 565-1343
Gaylord Hospital understands how important it is to protect your medical information. We are committed to ensuring confidentiality and security of your information and supporting your privacy rights.