Yakima Neighborhood
Health Services 12 South 8 th St, PO Box 2605 Yakima WA 98907-2605 Phone
(509) 454-4143 Fax (509) 454-3651 www.ynhs.org
Notice of Privacy Practices
- Acknowledgement
Effective April 14, 2003
We keep a record of the health care services we provide you. You may ask
to see and copy that record. You may also ask to correct that record.
We will not disclose your record to others unless you direct us to do
so or unless the law authorizes or compels us to do so. You may see your
record or get more information about it by contacting our Health Care
Information department at the clinic, or the Primary Care Administrator
(Privacy Officer) if you have a specific concern or would like more information
about our Privacy Practices. Our Notice of Privacy Practices describes
in more detail how your health information may be used and disclosed,
and how you can access your information.
By my signature below I acknowledge receipt of the Notice of Privacy Practices.
____________________________________________________________
Signature of patient or authorized representative
_________________________________
Date
______________________________________
Printed
name if signed on behalf of patient Relationship (parent, legal guardian,
personal representative, etc.)
Staff Comments (if needed) ___________________________________________________________________________
__________________________________________________________________________________________________
This form will be retained in your medical record
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.
Yakima Neighborhood Health Services respects your privacy. We understand
that your personal health information is very sensitive. We will not disclose
your information to others unless you tell us to do so, or unless the
law authorizes or requires us to do so. The law protects the privacy of
the health information we create and obtain in providing our care and
services to you. For example, your protected health information includes
your symptoms, test results, diagnoses, treatment, health information
from other providers, and billing and payment information relating to
these services. Federal and state law allows us to use and disclose your
protected health information for purposes of treatment and health care
operations. State law requires us to get your authorization to disclose
this information for payment purposes.
Examples of Use and Disclosures of Protected Health
Information for Treatment, Payment, and Health Operations
For treatment:
* Information
obtained by a nurse, physician, or other member of our health care team
will be recorded in your medical record and used to
help decide what care may be right for you.
* We may also provide information to others providing your
care. This will help them stay informed about your care.
For payment:
* We request payment from your health insurance plan (if you
have one). Health plans need information from us about your
medical care. Information provided to health plans may include your diagnoses,
procedures performed, or recommended care.
For health care operations:
* We use your medical records to assess quality and improve
services.
* We may use and disclose medical records to review the qualifications
and performance of our health care providers and to
train our staff.
* We
may contact you to remind you about appointments and give you information
about treatment alternatives or other health-related
benefits and services.
* We may contact you to raise funds.
* We may use and disclose your information to conduct or arrange
for services, including:
o
medical quality review by your health plan;
o accounting, legal, risk management, and
insurance services;
o audit functions, including fraud and abuse
detection and compliance programs.
Your
Health Information Rights
The health and billing records we create and store are the property of
the Yakima Neighborhood Health Services. The protected health information
in it, however, generally belongs to you. You have a right to:
* Receive, read, and ask questions about this Notice;
* Ask us to restrict certain uses and disclosures. You must
deliver this request in writing to us. We are not required to grant
the request. But we will comply with any request granted;
* Request and receive from us a paper copy of the most current
Notice of Privacy Practices for Protected Health Information
("Notice");
* Request that you be allowed to see and get a copy of your
protected health information. You may make this request in writing.
We have a form available for this type of request.
* Have us review a denial of access to your health information‹except
in certain circumstances;
* Ask us to change your health information. You may give us
this request in writing. You may write a statement of disagreement
if your request is denied. It will be stored in your medical record, and
included with any release of your records.
* When you request, we will give you a list of disclosures
of your health information. The list will not include disclosures to
third party payors. You may receive this information without charge once
every 12 months. We will notify you of the cost involved
if you request this information more than once in 12 months.
* Ask that your health information be given to you by another
means or at another location. Please sign, date, and give us
your request in writing.
* Cancel prior authorizations to use or disclose health information
by giving us a written revocation. Your revocation does
not affect information that has already been released. It also does not
affect any action taken before we have it. Sometimes,
you cannot cancel an authorization if its purpose was to obtain insurance.
For help with these rights during normal business hours, please contact:
Rhonda Hauff, Primary Care Administrator (Privacy Official) Yakima Neighborhood
Health Services (509)454-4143
Our
Responsibilities
We are required to:
* Keep your protected health information private;
* Give you this Notice;
* Follow the terms of this Notice. We have the right to change
our practices regarding the protected health information we
maintain. If we make changes, we will update this Notice. You may receive
the most recent copy of this Notice by calling and asking
for it or by visiting our clinic to pick one up.
To Ask for Help or Complain
If you have questions, want more information, or want to report
a problem about the handling of your protected health information, you
may contact:
Rhonda Hauff, Primary Care Administrator (Privacy Official) (509)454-4143
If you believe your privacy rights have been violated, you may discuss
your concerns with any staff member. You may also deliver a written complaint
to Rhonda Hauff, Primary Care Administrator at our clinic. You may also
file a complaint with the U.S. Secretary of Health and Human Services.
We respect your right to file a complaint with us or with the U.S. Secretary
of Health and Human Services. If you complain, we will not retaliate against
you.
Other Disclosures and Uses of Protected Health Information
Notification of Family and Others
* Unless you object, we may release health information verbally
about you to a friend or family member who we believe is involved
in your medical care. We may also give information to someone who helps
pay for your care. We may tell your family or friends
your condition and that you are in a hospital.
In addition, we may disclose health information about you
to assist in disaster relief efforts.
We may use and disclose your protected health information
without your authorization as follows:
* With medical researchers - if the research has been
approved and has policies to protect the privacy of your health information.
We may also share information with medical researchers preparing to conduct
a research project.
* To Funeral Directors/Coroners consistent with applicable
law to allow them to carry
out their duties.
* To Organ Procurement Organizations (tissue donation
and transplant) or persons who obtain, store, or transplant organs.
* To the Food and Drug Administration (FDA) relating
to problems with food, supplements, and products.
* To comply with workers' compensation laws --if you
make a workers' compensation claim.
* For Public Health and Safety purposes as allowed or required
by law:
o to prevent or reduce a serious, immediate threat to the
health or safety of a person or the public.
o to public health or legal authorities o to protect public
health and safety
o to prevent or control disease, injury, or disability
o to report vital statistics such as births or deaths.
* To report suspected Abuse or Neglect to public authorities.
* To Correctional Institutions if you are in jail
or prison, as necessary for your health and the health and safety of others.
* For Law Enforcement purposes such as when we
receive a subpoena, court order, or other legal process, or you are the
victim of a crime.
* For Health and Safety oversight activities. For example,
we may share health information with the Department of Health.
* For Disaster Relief Purposes. For example, we
may share health information with disaster relief agencies to assist in
notification of your condition to family or others.
* For Work-Related Conditions That Could Affect Employee
Health. For example, an employer may ask us to assess health
risks on a job site.
* To the Military Authorities of U.S. and Foreign Military
Personnel. For example, the law may require us to provide information
necessary to a military mission.
* In the Course of Judicial/Administrative Proceedings at
your request, or as directed by a subpoena or court order.
* For Specialized Government Functions. For example,
we may share information for national security purposes.
Other
Uses and Disclosures of Protected Health Information
* Uses and disclosures not in this Notice will be made only
as allowed or required by law or with your written authorization.
Web Site
* We have a Web site that provides information about us.
