Our Privacy Commitment

NOTICE OF PRIVACY PRACTICES 

Effective Date: September 23, 2013 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

 If you have any questions about this notice, please contact:

 Director of Health Information Management
The South Bend Clinic
211 North Eddy Street
South Bend, Indiana 46617

 This notice describes The South Bend Clinic’s practices and that of:

  • Any health care professional authorized to enter health information into your chart.
  • All departments, units, sites and locations of The South Bend Clinic.  All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share health information with each other for treatment, payment or clinic operational purposes described in this notice.
  • All employees, staff, students and other personnel authorized to document in and or review your chart.
  • All independent contracting staff and providers The South Bend Clinic may determine is necessary to help you with your care.  Those services include, but are not limited to: anesthesia, laboratory, surgical, and radiological services.  

OUR PLEDGE REGARDING HEALTH INFORMATION:

 We understand that health information about you and your health is personal.  We are committed to protecting health information about you. We create a record of the care and services you receive at The South Bend Clinic. 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 South Bend Clinic, whether made by authorized personnel or your personal physician.  This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:

  • make sure that health information that identifies you is kept private; 
  • give you this notice of our legal duties and privacy practices with respect to health information about you; and
  • follow the terms of the notice that is currently in effect. 

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in each category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

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, health care students, or other clinic personnel who are involved in your care and treatment. Different departments of The South Bend Clinic also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside The South Bend Clinic who may be involved in your medical care. The exception to this is that most uses and disclosures of psychotherapy notes require your authorization. 

For Billing Purposes: 
We may use and disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at The South Bend Clinic so your health plan will reimburse you for the related costs. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the proposed treatment. (See also “Rights to Request Restrictions” below regarding your rights to restrict health information to the health plan.”) 

For Health Care Operations: 
We may use and disclose health information about you for general business operations. These uses and disclosures are necessary to operate The South Bend Clinic and to make sure that all of our patients receive quality care. For Example: we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information to determine what additional services The South Bend Clinic should offer, what services are not needed, and whether certain new treatments are effective.

We may also disclose information to doctors, nurses, technicians, medical students, and other clinic personnel for review and learning purposes. We may also combine the health information we have with health information from other physician practices 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 identifying the specific patient[s].

Treatment Alternatives: 
We may use and disclose health 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 health information to tell you about health-related benefits or services that may be of interest to you. Uses and disclosure of health information for marketing purposes or sale of health information requires your authorization.  You may be contacted for fund raising purposes; however, you have the right to opt out of such communication(s).

Individuals Involved in Your Care or Payment for Your Care:
We may release health information about you to a friend or family member that you have requested to be involved in your medical care. We may also give information to an insurance company or someone who helps pay for your care. 

As Required By Law:
We will disclose health information about you when required to do so by federal, state or local law.

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.  Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Organ and Tissue Donation:
If you are an organ donor, we may release 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.

Military and Veterans:
If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation:
We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks:We may disclose health information about you for public health activities. These activities generally include the following:

  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report abuse or neglect;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • 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;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities:
We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These necessary activities allow the government to monitor the health care system, government sponsored programs, and compliance with laws and regulations.

Lawsuits and Disputes:
If you are involved in a lawsuit or a legal dispute, we may disclose health information about you in response to 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 efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement:
We may release health information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at the on our premises; and
  • In emergency circumstances; to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors:
We may release 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. We may also release health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities:
We may release health 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 health 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.

Inmates:
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary:

  1. for the institution to provide you with health care;
  2. to protect your health and safety or the health and safety of others; or
  3. for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy:
You have the right to inspect and obtain a copy of your health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. 

You have the right to inspect and to obtain a copy of health information that may be used to make decisions about you. Please submit your request in writing to:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617

If you request a copy of health information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by The South Bend Clinic will review your request and the denial. The person conducting the review will not be the person who denied your original request. The South Bend Clinic will comply with the outcome of the review.

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 for as long as the information is kept by The South Bend Clinic.

To request an amendment, your request must be made in writing and submitted to:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617

 In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the 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 South Bend Clinic;
  • Is not part of the health information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

Right to an Accounting of Disclosures:
You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of health information about you. To request this list or accounting of disclosures, you must submit your request in writing to:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617 

Your request must state a time period which may not be longer than six 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 Restrictions:
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment* or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in 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 are not required to agree to this type of request. If we do agree, we will comply with your request unless the information is necessary for emergency treatment. 

*You have the right to restrict certain disclosure of your health information to health plans where you may pay out-of-pocket in full for healthcare items or services. However, The South Bend Clinic will determine what payment is required in order to have the service considered “paid in full”.

To request restrictions, you must make your request in writing to:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617 

In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

 Right to be notified of a Breach:
You have the right to receive notification of a breach of your unsecured health information.  If we become aware that your health information has become unsecure and accessed by an unauthorized individual or entity, you will be notified.If you become aware that your health information has become unsecure, please notify us.  Contact:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617 

Right to Request Confidential Communications: 
You have the right to request that we communicate with you about medical 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. To request confidential communications, you must make your request in writing to:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617  

 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 a Paper Copy of This Notice:
You have the right to a paper copy of this notice. You may ask us to give you 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. To obtain a paper copy of this notice, you may access The South Bend Clinic’s internet site www.southbendclinic.com and print a copy or contact:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617 

 CHANGES TO THIS NOTICE

The South Bend Clinic reserves the right to change this notice. The South Bend Clinic reserves the right to make the revised or changed notice effective for health information we already have regarding you as well as any information we receive in the future. The South Bend Clinic will post a copy of the current notice throughout the clinic. The notice will contain, on the first page, in the top center of the page, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with The South Bend Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with The South Bend Clinic, contact:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617  

 All complaints must be submitted in writing. 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 no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

THE SOUTH BEND CLINIC PRIVACY ACKNOWLEDGEMENT

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you or any person for whom you have legal authority to make health care decisions. You have the right to review our notice before signing an acknowledgement. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by accessing The South Bend Clinic’s internet site www.southbendclinic.com and print a copy or contact the following to request a copy:

Director of Health Information Management
211 North Eddy Street
South Bend, Indiana 46617 

Thank you for allowing The South Bend Clinic the opportunity to assist you with your medical needs.

 

THE SOUTH BEND CLINIC PRIVACY ACKNOWLEDGEMENT

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction request, but if we do, we are bound by our agreement.

You have the right to restrict certain disclosure of your health information to health plans where you may pay out-of-pocket in full for healthcare items or services. However, facility has the ability to determine what is “paid in full”. 

By signing this form, you agree to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this acknowledgment, in writing, except where we have already made disclosures in reliance on your prior acknowledgement.

 

Patient Name: _________________________________ Date of Birth: __________

 

Patient/Guardian Signature: ____________________________________________

 

Relationship to Patient: _________________________________________________

 

Date: _________________________________