Privacy Statement
Memorial Health Care System (MHCS) 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. If you have any questions about this notice, please contact Memorial's HIPAA Privacy/Security Officer at (423) 495-7845.
MHCS is required by law to maintain the privacy of your health information; give you notice of our legal duties and privacy practices with respect to your health information; and follow the terms of this notice. This notice applies to all of your health records generated by MHCS, whether made by our personnel or your personal physician. This notice will tell you about the ways in which we may use and disclose your health information. We also describe your rights and certain obligations we have regarding the use and disclosure of your health information.
I. How we may use and disclose your health information
For Treatment. We will use your health information to provide you with health care treatment and to coordinate or manage services with other health care providers, including third parties.
We may disclose all or any portion of your health information:
- To your attending physician, consulting physician(s), nurses, technicians, medical students, or other MHCS or health care personnel who have a legitimate need for such information in order to take care of you. Different departments of MHCS will share your health information in order to coordinate the health care services you need, such as prescriptions, lab work and X-rays.
- To family members or friends, guardians or personal representatives who are involved with your medical care.
- To contact you for appointment reminders, and to provide you with information about possible treatment options or alternatives, and other health-related benefits and services.
- To people outside the facility who may be involved in your health care after you leave the facility, such as other physicians involved in your care, specialty hospitals, home health care, skilled nursing care facilities and other health care-related services.
Organized Health Care Arrangement. MHCS is a clinically integrated health care setting. You may receive health care services from your personal physician, other physicians who are members of the medical staff, practitioners who have clinical privileges to practice at MHCS and from MHCS employees.
Your physician, practitioners and MHCS must be able to share your health information in order to provide you with quality health care, receive payment and conduct health care operations. The members of the medical staff, practitioners and MHCS have agreed to follow uniform health information practices when using or disclosing your health information while you are at MHCS, either as an inpatient or for outpatient services. This arrangement is called an organized health care arrangement. This arrangement only applies when you receive the health care services at MHCS. It does not apply to the information practices at the physician's office or other private practices.
The organized health care arrangement includes MHCS, the physicians and members of the medical staff, and the independent practitioners who have clinical privileges to practice at MHCS. This also includes independent practitioners who practice exclusively at MHCS such as radiologists, anesthesiologists, pathologists and emergency room physicians.
An example of how MHCS members of the medical staff and independent practitioners share your health information include hospital committees to discuss the quality of care and ways to improve health care services to you and the community.
You will receive a Notice of Privacy Practices form on behalf of MHCS, members of the medical staff and independent practitioners for the health care services received at MHCS. You will also receive a Notice of Privacy Practices form from your personal physician or practitioner that describes his or her own office information practices.
For Payment. We will use and disclose your health information for activities that are necessary to receive payment for our services, such as determining insurance coverage, billing, payment and collection, claims management and medical data processing. For example, we may tell your health plan about a treatment you are planning in order to receive approval or to determine whether your plan will cover the proposed treatment. We may disclose your health information to other health care providers so they can receive payment for health care services that they provided to you, such as ambulance services. We may also give information to other third parties or individuals who are responsible for payment for your health care.
For Health Care Operations. We may disclose your health information for routine facility operations, such as business planning and development, quality review of services provided, internal auditing, accreditation, certification, licensing or credentialing activities, medical research and education for staff and students, and to other health care entities that have a relationship with you and need the information for operational purposes.
Facility Directory. We may include your name, location in the facility, your general condition (for example, fair or stable, or even the death of a person) and your religious affiliation in the facility directory. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your name and religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. The facility directory is available so your family, friends and clergy can visit you and generally know how you are doing. You must notify Memorial's Registration Department by phone at (423) 495-3817 or in writing if you do not want us to release information about you in the facility directory. If you do not want information released in the facility directory, we cannot tell your family, friends or the general public that you are in the hospital. We will not be able to deliver flowers or mail to your room.
Fundraising Activities. We may use your health information or disclose your health information to a foundation related to us for MHCS fundraising efforts. We would only release information such as your name, address and phone number and the dates that you received treatment or services from us. If you do not want us to contact you for fundraising efforts you must notify Memorial's Foundation Department at (423) 495-4144 in writing, stating that you do not want to receive the information.
Research. We may use and disclose your health information to researchers when the Institutional Review Board and/or Privacy Board approve the research study and the use of your health information.
Organ and Tissue Donation. If you are an organ donor, we may release your health information to organizations that handle organ procurement and transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
II. Uses and disclosures that are required or permitted by law
Subject to requirements of federal, state and local laws, we are either required or permitted to report your health information for various purposes. Some of these reporting requirements include:
Public Health Activities. We may disclose your health information to public health officials for activities such as the prevention or control of communicable disease, injury or disability; to report births and deaths; to report suspected child abuse or neglect; to report reactions to medications or problems with medical products.
Disaster Relief Efforts. We may disclose your health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition and location.
Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities may include 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.
Judicial or Administrative Proceeding. We may disclose your health information in response to a court or administrative order, a valid subpoena, discovery request, civil or criminal proceedings, or other lawful process.
Law Enforcement. We may release your health information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar legal process;
- Regarding a victim or death of a victim of a crime in limited circumstances
- 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, including crimes that may occur at our facility.
Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or a medical examiner. This may be necessary, for example, to identify a person who died or determine the cause of death. We may also release health information to help a funeral director carry out their duties.
Workers' Compensation. We may release your health information for workers' compensation benefits or to similar programs that provide benefits for work-related injuries or illness.
To Avert a Serious Threat to Health or Safety. We may disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public.
National Security. We may disclose your health information to federal official(s) for national security activities and for the protection of the President and other Heads of State.
Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may release your health information to the institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; or (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.
Other uses of your health information. Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written authorization. Submit your request in writing, using a Authorization for Disclosure of Protected Health Information form to Health Information Services, 2525 deSales Ave., Chattanooga, TN 37404. Phone (423) 495-8285. If you provide us with authorization to use or disclose your health information, you may revoke that authorization in writing at any time. When we receive your written revocation we will no longer use or disclose your health information for the purpose of that authorization. However, we are unable to retrieve any disclosures already made based on your prior authorization.
III. Your rights regarding your health information
Right to Inspect and Copy. You have the right to inspect your health information and copy medical, billing or other records that may be used to make decisions about your care. Submit your request in writing to Health Information Services, 2525 deSales Ave., Chattanooga, TN 37404. Phone (423) 495-8285. We charge a fee for document requests to cover the costs of copying, mailing or other supplies. In limited circumstances we may deny your request to inspect and copy your health information. If you are denied access to your health information, you may request that the denial be reviewed. A licensed health care professional chosen by MHCS will review your request and the denial. The person who conducts the review will not be the same person who denied your request. We will comply with the outcome of the review.
Right to Amend. You have the right to request an amendment to your health information that you believe is incorrect or incomplete. Submit your request in writing, using a Request for Amendment to Protected Health Information form, and including your reason for the amendment, to Health Information Services, 2525 deSales Ave., Chattanooga, TN 37404. Phone (423) 495-8285.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that:
Was not created by MHCS; unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the medical information kept by or for MHCS; Is not part of the information that you would be permitted to inspect and copy; or; Is accurate and complete.
To obtain a paper copy of this request, contact Health Information Services, 2525 deSales Ave., Chattanooga, TN 37404. Phone (423) 495-8285.
Right to an Accounting of Disclosures. We are required to maintain a list of disclosures of your health information. However, we are not required to maintain a list of disclosures that we made by acting upon your written authorizations. You have the right to request an accounting of disclosures that were not subject to your written authorization. Submit your request in writing to Health Information Services, 2525 deSales Ave., Chattanooga, TN 37404. Phone (423) 495-8285. Your request must state a time period, not longer than six years, and may not include dates before April 14, 2003. This will be available in paper and electronic format. 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 before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on how much of your health information we use or disclose for treatment, payment or health care operations. You also have the right to request a restriction on the disclosure of your health information to someone who is involved in your care or payment for your care, such as a family member or friend.
We are not required to agree to your request. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Submit your request in writing to Health Information Services, 2525 deSales Ave., Chattanooga, TN 37404. Phone (423) 495-8285, or request and submit a Request for Restrictions to Protected Health Information form. You must include: (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.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at an alternative location from your home address, such as work, or only contact you by mail instead of by phone. You must submit a Confidential Communications form to Memorial Business Office, 2525 deSales Ave., Chattanooga, TN 37404. Phone (423) 495-8629. Your request must specify how or where you wish to be contacted. We do not require a reason for the request. We will accommodate all reasonable requests.
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. To obtain a paper copy of this notice, contact Memorial's HIPAA Privacy/Security Officer at (423) 495-7845.
Changes to this notice. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the facility and on the web site at MHCS. The notice will contain on the first page, in the top right-hand corner, the effective date. Upon your initial registration or admittance to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect. Whenever the notice is revised, it will be available to you upon request.
Complaints
You may file a complaint with us or with the Secretary of the Department of Health and Human Services if you believe that we have not complied with our privacy practices. You may file a complaint with us verbally or in writing by contacting Memorial's HIPAA Privacy/Security Officer at (423) 495-7845. You will not be penalized for filing a complaint.
159803 5 Notice of Privacy Practices (4/03)
Downloadable Forms
Authorization for Disclosure of Protected Health Information
Request for Amendment of Protected Health Information (PHI)
