Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
- basis for planning your care and treatment
- means of communication among the many health professionals who contribute to your care
- legal document describing the care you received
- means by which you or a third-party payer can verify that services billed were actually provided
- tool in educating health professionals
- source of data for medical research
- source of information for public health officials charged with improving the health of the nation
- source of data for facility planning and marketing
- tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to:
Ensure its accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosures to others.
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that maintains it, you have certain rights regarding the information. Subject to certain standards and requirements, you have the right to:
- request a restriction on certain uses and disclosures of your information as provided by applicable law (please note that we are not required by law to agree to your requested restriction, except if you request that we not disclose information to a health plan for payment or health care operations and the information relates only to a health care item or service for which we have been paid in full by you or a person other than the health plan)
- obtain a paper copy of the notice of privacy practices upon request
- inspect and obtain a copy of your health record as provided by applicable law (charges for copies may apply)
- request an amendment to your health record as provided by applicable law
- obtain an accounting of disclosures of your health information as provided by applicable law
- request communications of your health information by alternative means or at alternative locations
- revoke your authorization to use or disclose health information except to the extent that action has already been taken
- request and obtain your protected health information in an electronic format if it Is readily producible by the organization in such format
Subject to the terms of this notice and applicable law, this organization is required to:
- maintain the privacy of your health information
- provide you with a notice as to our legal duties and privacy practice with respect to health information we collect and maintain about you
- abide by the notice of privacy practices currently in effect
- accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
- obtain your authorization for uses and disclosures of you protected health information for certain marketing purposes
- notify affected individuals of a breach of unsecured protected health information
- obtain authorization for most uses and disclosures of most psychotherapy notes created by this organization
- obtain authorization for most uses and disclosures involving the sale of protected health information. The authorization would need to state that the organization is being paid for the protected health information.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. We will not use or disclose your health information without your authorization, except as described in our notice.
For More Information or To Report A Problem
If you have questions and would like additional information, you may contact our Patient Advocate at (540) 332-4742 or (540) 932-4742.
If you believe your privacy rights have been violated, you can file a complaint with the Director of Health Information Management at (540) 932-4645, with the Corporate Compliance and Privacy Officer at (540) 245-7455, or the confidential toll-free Compliance Hotline at 1-855-298-5598, or by contacting the Secretary of U.S. Department of Health and Human Services.
There will be no retaliation for filing a complaint.
Examples of Uses and Disclosures for Treatment, Payment and Health Operations:
We will use and disclose your health information for treatment.
For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that would work best for you, and disclosed to healthcare providers for your treatment. Your physician may document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.
We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from this hospital.
We will use and disclose your health information for payment.
For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use and disclose your health information for regular health care operations.
For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information may then be used and disclosed in our programs for continually improving the quality and effectiveness of the healthcare and service we provide.
Business associates: There are some services provided in our organization through contracts with business associates. An example could include a copy service that provides staff to perform record copying functions. To protect your health information, the law requires the business associate to appropriately safeguard your information and enter into business associate agreements with their own subcontractors who are also required to safeguard your Information.
We may also use and disclose protected health information as outlined below:
Directory: Unless you notify us that you object, we may give your location and general health condition to those individuals who call and ask for you by name. Your religious affiliation may be provided to members of the clergy.
Notification: We may use or disclose information, such as your location and general condition, to notify or assist in notifying a family member, personal representative, or another person responsible for your care.
Communication with family: Unless you object, health professionals, using their professional judgment, may disclose to a family member, other relative, friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Research: We may use and disclose information for research purposes. Typically, prior to disclosing your information to researchers, we will either obtain your written authorization, or will require separate approval by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities, engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
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.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Food and Drug Administration (FDA): We may disclose certain health information to the FDA relative to adverse events with respect to food, supplements, medications, product and product defects, medical devices, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public health: We may disclose medical information about you for public health activities. These activities may include activities: to prevent or control disease, injury or disability; to report births and deaths; and to report child abuse or neglect.
Fundraising: We may use and disclose information for fundraising purposes as specifically permitted by law, which includes contact information (such as your name, address and phone number), information about your treating physician, the department where you received care, clinical outcome information, the dates you received treatment or services and other information allowed by law. This information may be used by us and disclosed to a foundation related to Augusta Health so that the foundation may contact you in raising money for us. You have a right to opt-out of receiving fundraising communications and if you elect not to receive those, we will comply with that request. If you do not want to be contacted for fundraising, you should call the Office of the Vice President–Funds Development, at (540) 332-4858, to opt-out of receiving the communications.
Accrediting, Licensing and Regulatory Reviews: Professionals associated with healthcare accrediting, licensing, or regulatory agencies for survey purposes may view your health information.
Correctional institution: If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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, after efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law enforcement: We may release medical information if asked to do so by a law enforcement official to identify or locate a suspect, fugitive, material witness, or missing person. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. We may also disclose information about criminal conduct at our facilities, and in emergency circumstances to report a crime.
Coroners and Medical Examiners: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities: We may release medical information about you to authorized federal officials 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 officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law, and may disclose information as otherwise permitted by applicable law.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
Alcohol and Drug Treatment Patient Records
In addition to the protections described above, the confidentiality of alcohol and drug treatment patient records maintained by certain treatment programs are protected by other Federal laws and regulations. Generally, programs may not tell a person outside of the program that a patient attends a program for alcohol or drug abuse treatment, or disclose information identifying a patient as an alcohol or drug abuser unless (i) the patient consents in writing, (ii) the disclosure is allowed by a court order, or (iii) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, or audit or evaluation of the program. Programs may also disclose information about a crime committed by a patient either at the program, or against any person who works for the program. These federal laws and regulations likewise permit the program to disclose information about suspected child abuse or neglect, consistent with state law.
For a minor who is legally entitled to consent to treatment without parental consent, consent of the minor will be obtained before information is shared with a parent or guardian. In cases in which the consent of a parent or guardian is required for treatment and the minor is capable of making a rational choice, before sharing information with a parent or guardian, the program will seek the consent of the minor. For patients who have been legally found to be incapacitated, information may be shared with the guardian or other person entitled to act on behalf of the patient.
Under the special laws and regulations applicable to alcohol and drug treatment program records, among other differences, patients in the alcohol and drug treatment program typically will not be listed in the patient directory. Also, information about alcohol or drug treatment and information identifying an individual as an alcohol or drug treatment patient will typically not be disclosed to family members and relatives of the patient unless a special exception applies. Violation of the special confidentiality requirements for alcohol and drug abuse treatment programs is a crime, and suspected violations may be reported to appropriate authorities in accordance with Federal regulations.