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HIPAA Privacy Notice

Dan Wyand & Associates, PT / Kingdom Emergency Services / Women's Wellness Center / NVRH Anesthesia Group / NVRH Corner Medical/ NVRH St Johnsbury Pediatrics / NVRH Orthopaedic Group / NVRH Surgical Group/NVRH Kingdom Internal Medicine/NVRH ENT Group/NVRH Specialty Clinics

Notice of Privacy Practices


Our legal duty to protect health information about you
We are required to protect the privacy of the health information about you that can be identified with you. This Notice explains our legal duties and privacy practices concerning your protected health information (PHI). This notice is also provided to you on behalf of other health care professionals, including but not limited to those listed above, who are closely connected to NVRH. These professionals will not issue you a separate Notice because they have agreed to follow our privacy practices regarding your PHI.

By law, we are required to give you this Notice.

  • We must protect health information that we have created or received about your past, present, or future health condition
  • We must protect PHI about health care we provide to you
  • We must notify you about how we protect PHI about you
  • We must explain how, when, and why we use and/or disclose PHI about you
  • We may only use and/or disclose PHI as we have described in this Notice

We are required to follow the procedures in this Notice. This notice will be effective for all protected health information that we have at that time and for future information.

Our current Notice is posted in the registration area near the emergency room. Copies of the current notice are available upon request.

We may use and disclose protected health information (PHI) for:

Health Care Treatment
We may use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination of your health care with a third party.

Example: A doctor treating you for a broken leg may need to know from another doctor that you have diabetes because diabetes may slow the healing process of your leg. The doctor may tell the dietician so that food service can provide appropriate meals. Departments of the hospital such as the lab, x-ray, and pharmacy may have to share information in order to coordinate the different services you may need while you are in the hospital. We may also need to notify home health if you will be using their services after you leave the hospital.

Payment For Services
Your PHI will be used, as needed, to obtain payment for your health care services. This may include contacting your health insurance plan for authorization or approval before you receive the services.

We may share your PHI with the following:

  • Billing departments
  • Collection departments or agencies
  • Consumer reporting agencies (credit bureaus)
  • Insurance companies, health plans, and their agents
  • Hospital departments that review the care you receive for medical necessity and utilization review activities

Health Care Operations
We may use or disclose your PHI in order to support the business operations of the hospital.

Example: We may hire an outside billing service to assist us in collecting past due balances. We will have a written contract that contains terms that will protect your PHI whenever an arrangement between our hospital and that billing service involves the use or disclosure of your PHI.

Health care operations include but are not limited to:

  • Reviewing and improving the quality, efficiency, and cost of care that we provide you and other patients. For example, we may use PHI about you to develop ways to assist our health care providers in deciding what medical treatment to use for others.
  • Improving health care and lowering costs for groups of people who have similar health problems to help manage and coordinate the care for these groups of people. We may use PHI to identify groups of people with similar health problems to give them information about treatment options, classes, or new procedures.
  • Reviewing and evaluating the skills, qualifications, and performance of health care providers.
  • Providing training for students or trainees of health care professionals or non-health care professionals (billing clerks etc.) to help them practice or improve their skills.
  • Cooperating with outside agencies that assess the quality of care we and others provide. For example, the Joint Commission of Accreditation on Healthcare Organizations.
  • Cooperating with outside organizations that evaluate, certify, or license health care providers, staff, or facilities. For example, we may disclose PHI about you so that one of our nurses may become certified as having expertise in a specific field of nursing.
  • Assisting various people who review our activities. For example, PHI may be seen by doctors, lawyers, or accountants who are assisting us comply with applicable laws and regulations.
  • Planning for our future operations and for fundraising activities that benefit our organization and the people we serve.
  • Conducting business management and general administrative activities related to our organization and the services we provide.
  • Resolving grievances within our organization.
  • Complying with this Notice and applicable laws.

Other circumstances when we may use or disclose your PHI without your authorization

  • Required by law: We may use or disclose your PHI to the extent required by law. The use and disclosure will be made in compliance with the law and is limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses and disclosures.
  • Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is required or permitted by law to receive the information. This disclosure will be made for the purpose of controlling or reporting disease, injury, or disability. We may also disclose your PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Examples of public health include: communicable diseases, incidents of abuse or neglect, the Federal Drug Administration to report adverse events or product defects, and the maintenance of vital statistics such as births and deaths.
  • Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies include government agencies that oversee health care systems, government benefit programs, other government regulatory programs and civil rights laws.
  • Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of the court or administrative tribunal, and in certain conditions in response to a subpoena, discovery request or other lawful process.
  • Law Enforcement: We may also disclose PHI for law enforcement purposes, as long as applicable legal requirements are met. Law enforcement purposes include: legal processes and those otherwise required by law, limited information requests for identification and location purposes, pertaining to victims of a crime, suspicion that death has occurred as a result of criminal conduct, in the event that a crime occurs on the premises, and in a medical emergency where it is likely a crime has occurred.
  • Coroners, Funeral Directors, Organ Donation: We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for other duties performed by the coroner or medical examiner as authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order for the funeral director to carry out their duties. PHI may be used and disclosed for organ, eye, or tissue donation purposes.
  • Research: We may disclose PHI to researchers when their research has been approved by an institutional review board that has established protocols to ensure the privacy of your protected health information. Otherwise, we will ask for a written authorization from you.
  • Criminal Activity: Consistent with federal and state laws, we may disclose your PHI if we believe the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
  • Military Activity and National Security: When the appropriate conditions apply, we may disclose PHI of individuals who are Armed Forces personnel for activities deemed necessary by military command authorities, in order for the Department of Veterans Affairs to determine your eligibility for benefits, or to foreign military authority if you are a member of a foreign military service. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities.
  • Workers' Compensation: Your PHI may be disclosed by us as authorized to comply with workers' compensation laws.
  • Inmates: We may use or disclose your PHI to the correctional facility having legal custody of you if you are an inmate.
  • Vermont Required Disclosures: Vermont Law requires reporting in the following cases: child abuse; abuse, neglect or exploitation of vulnerable adults; fire-arm related injuries; communicable diseases; fetal deaths; cancer; lead poisoning; blood-alcohol reporting; duty to warn of harm cases. We will disclose information limited to the relevant requirements of the law.

We may contact you under the following circumstances:

For appointment reminders
We may use or disclose your PHI to contact you to remind you of an appointment.

With information about treatment, services, products, or health care providers

We may use or disclose PHI to manage or coordinate your health care. This may include telling you about treatments, services, products, or healthcare providers.

Example: If you are diagnosed with diabetes, we may tell you about self-management classes or support groups that may be of interest to you.

For fund-raising activities
We may use or disclose PHI about you, including disclosure to a foundation, to contact you to raise money for the hospital and its operations. We will only release contact information and the dates you received treatment or services at the hospital.

You may opt out of fundraising activities at NVRH. If you do not want to be contacted for fundraising purposes, you must notify NVRH in writing.

You may object to certain uses and disclosures of your protected health information (PHI).
There are certain uses and disclosures of your PHI that you may agree or object to:

  • Facilities Directory: Unless otherwise requested, your name is added to the hospital's patient directory upon admission to NVRH. Directories are available in the Access Department (near the ER entrance) and at the information desk in the main lobby. Being on the directory allows you to receive phone call, visitors, flowers, and mail. When a visitor arrives or calls and asks for you by name we will provide them with your room number. We may also give out your condition (good, fair, serious, critical, or undetermined). If a caller or visitor does not identify you by name, no information is given out.
  • Clergy Directory: Unless otherwise requested, your religious preference may be provided to ministers of the faith you designate. Area clergy are permitted access to a list of patients who share their religious affiliation. The NVRH Chaplain is permitted access to the directory of all patients. If you want to be included on your clergy's list, you should identify your religion upon registration. Remember you have the right to remain anonymous and request that no information be given out to anyone. During the registration process, you will be given the option to opt off the "clergy directory" or the "family and friends directory" or both. If you choose to opt out of the family directory you will not receive phone calls, flowers, visitors etc.
  • Emergencies: We may share with a public or private agency (for example, the American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may share PHI you if necessary for emergency circumstances.

Uses and disclosures that require your written authorization

Psychotherapy Notes
NVRH is dedicated to protecting the privacy of all your health information including psychotherapy notes. We may only disclose your psychotherapy notes for limited purposes such as carrying out treatment. For other purposes, we will obtain your written consent.

Psychotherapy notes mean notes recorded by a mental health professional during a private counseling session, or a group or family counseling session. These notes may include medications, frequencies of treatment, results of clinical tests, and the treatment plan, and progress to date.

NVRH does not use protected health information (PHI) for the purpose of communicating about a product or service in order to encourage you to purchase that product or service.

We may contact you about a product or service if the product or service is directly treatment related, discussed face to face, or given as a promotional gift of nominal value.

Example: If you are diagnosed with diabetes, we may tell you about self-management classes or support groups that may be of interest to you.

You have rights regarding your protected health information (PHI).

You have the right to:

Request restrictions on uses and disclosures of PHI about you
You have the right to request that we restrict the use and disclosure of PHI about you for purposes of treatment, payment, or healthcare operations. We are not required to agree to your requested restrictions. Even if we agree to your request, there are some situations where your request will not be followed, such as in emergency situations.

Tell your nurse or unit manager if you want to restrict the use and disclosure of PHI about you. All requests will be reviewed by the care management department.

Request different ways to communicate with you
You have the right to request how and where we contact you about PHI. You can provide information about your preferred method of contacting you at the time of registration.

Example: You may prefer that we contact you at home instead of at work. If so, provide only your home phone number and address at the time of registration.

See and copy your PHI
You have the right to request to see and to receive a copy of the PHI contained in clinical, billing, and other records used to make decisions about you. We may charge you fees related to the copying of the records not to exceed the amount allowed by Vermont law.

If you agree, we will provide a summary or explanation of the PHI about you instead of a full copy.

There are certain circumstances in which we are not required to comply with your request. Under these circumstances, we will respond to your request in writing stating why we will not grant your request.

Request an amendment of PHI about you
You have the right to have your physician amend your PHI. You may request an amendment of PHI in a designated record for as long as we maintain this information.

We may deny your request if the information was not created by us, the information is not part of the records used to make decisions about you, or we believe the information is correct and complete.

Receive a listing of disclosures we have made of your PHI
You have the right to request a listing of disclosures we have made, if any, for purposes other than treatment, payment, or health care operations as described in this Notice.

Disclosures are not required for those we have made to you, incidental disclosures, disclosures you have authorized, disclosures for a facility directory, disclosures to family or friends involved in your care, or those made to carry out treatment, payment, or health care operations.

You have the right to receive specific information regarding disclosures that occurred after April 14, 2003 up to a six-year time frame. You may request a shorter time frame.

If you request a list more than once in 12 months, we may charge you a reasonable fee.

You can file a complaint about our privacy practices
You have the right to file a complaint with NVRH or with the Secretary of the Department of Health and Human Services.

Effective date of this notice
This Notice was published and becomes effective on April 14, 2003.

For more information please use the contact list below. You may be asked to provide a written request for some information.

For information about amending your protected health information or to see or obtain a listing of disclosures of your PHI contact:

NVRH Privacy Officer
PO Box 905
St. Johnsbury, VT 05819

To file a complaint about this Notice contact:
NVRH Quality Management
PO Box 905
St. Johnsbury, VT 05819

To get a copy of this Notice contact:
NVRH Marketing
PO Box 905
St. Johnsbury, VT 05819

If you do not want to be contacted for fundraising contact:
NVRH Development
PO Box 905
St. Johnsbury, VT 05819

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