Understanding Your Medical and Mental Health Record Information

Each time you visit a hospital, physician, or other healthcare provider, the provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your medical record, serves as a:

  • Basis for planning your care and treatment
  • Means of communication among the many health professional who contribute to your care
  • Legal document describing the care you received
  • Means by which you or a third-party payor can verify that you actually received the services billed for
  • A tool in medical education
  • A source of information for public health officials charged with improving the health of the regions they serve
  • A tool to assess the appropriateness and quality of care you received
  • A tool to improve the quality of healthcare and achieve better patient outcomes

Understanding what is in your health records and how your health information is used helps you to:

Ensure its accuracy and completeness

Understand who, what, where, why, and how others may access your health information

Make informed consent decisions about permitting disclosure to others

Better understand how to protect your right to confidentiality

Better understand the health information rights detailed below

Our Responsibility under the Federal Privacy Standard

Limestone Health has a duty to protect the privacy of health information about you, called “protected health information,” or “PHI,” for short. Limestone Health must give you notice of its legal duties and privacy practices concerning PHI. Limestone Health’ responsibilities including the following:

  • Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative and technical safeguards to protect the information
  • Provide you with this notice as to Limestone Health’ legal duties and privacy practices with respect to PHI about you
  • Explain how, when and why Limestone Health uses and/or discloses PHI about you
  • Abide by the terms of this Notice, as may be revised from time to time
  • Train Limestone Health personnel concerning privacy and confidentiality
  • Implement a sanction policy to discipline those who breach privacy/confidentiality or Limestone Health policies with regard thereto
  • Mitigate (lessen the harm of) any breach of privacy/confidentiality

Limestone Health will make copies of the Notice available at its facility upon request. Limestone Health will also post this Notice at the facility, so you may read it there, and on its website, so that you may receive it electronically.

Limestone Health reserves the right to change the terms of this Notice and to make the new provisions effective for all PHI it maintains. Should Limestone Health change this Notice, Limestone Health will promptly:

  • Post the revised Notice in its facility
  • Make copies of the revised Notice available upon request (either at the Limestone Health facility or through the contact person list on this Notice)
  • Post the revised notice on its website

Limestone Health will not use or disclose your health information without your consent or authorization, except as described in this Notice or as otherwise required by law.

Limestone Health may use and disclose PHI about you without your consent or authorization in the following circumstances:

In general, Limestone Health is required by law to obtain your written consent or authorization prior to using or disclosing your PHI that does not identify you as a substance abuser or a patient of the substance abuse services. However, there are exceptions to this requirement.

Treatment: Within Limestone Health, employees, students, consultants and volunteers involved in your case, treatment, or habilitation may exchange PHI as necessary for the purpose of carrying out their responsibilities in serving you. Upon specific request, your PHI may be released to the physician or psychologist who referred you to Limestone Health. A professional at Limestone Health may disclose your PHI, as necessary, to another physician or health care provider who provides you with emergency medical services.

Next of Kin: In addition, Limestone Health may disclose the fact of your admission or discharge to your next of kin, if the next of kin or the responsible professional determines that such disclosure is in your best interest. If you have next of kin who is substantially involved with your care, upon his or her request, Limestone Health shall provide this kin with information relating to your admission and discharge from Limestone Health, any decision on your part to leave Limestone Health against medical advice, and referrals and appointment information for treatment after discharge
after Limestone Health notifies you that such information was requested.

Business Associates: Limestone Health also may disclose your PHI to providers of support services who have entered into Business Associates Agreements with Limestone Health. Limestone Health provides some services through contracts with “Business Associates.” For example, Limestone Health may provide certain diagnostic tests through a third party, or it may contract with a copy service to make copies of medical records. These entities constitute Business Associates of Limestone Health; when the hospital contracts for these services, Limestone Health may disclose your PHI to a Business Associate including a subcontractor that acts on behalf of the Business Associate so that it can perform the function(s) Limestone Health has contracted with them to do and bill you or third party payor for services rendered. To protect your PHI, Limestone Health requires the Business Associate to appropriately safeguard your information in accordance with a written agreement.

Other Permitted Uses and Disclosures: In addition, Limestone Health may use or disclose PHI that does not identify you as a substance abuser or a patient of substance abuse services without your written consent or authorization as follows:

  • To an internal client advocate as necessary to fulfill his or her monitoring and advocacy functions
  • To disclose an advance instruction to a physician, psychologist or other qualified professional when such disclosure is necessary to give effect to or provide treatment in accordance with the
    advance instruction
  • To State or Federal governmental agencies, when there is reason to believe that you may be eligible for financial benefits through the government agency, to establish such financial
  • To the state for certain purposes of research and evaluation, or for conducting general research or audits
  • For the purposes of alerting others to an imminent danger to you, or another’s, health or safety, or if there is a likelihood of the commission of a felony or violent misdemeanor, or to
    communicate with appropriate law enforcement in the event of your escape from Limestone Health
  • To an attorney, upon your request or the request of your legally responsible person
  • As required by law – for example, when a court orders disclosure or when child abuse or neglect is suspected
  • For purposes of filing a petition for involuntary commitment or a petition for an adjudication of incompetency and the appointment of a guardian
  • As required by State law when you are a defendant in a criminal case, or to the court and counsel involved in any commitment or other court hearings you face
  • To Limestone Health counsel, or counsel for an employee of Limestone Health, if such information is relevant to litigation, to the operations of Limestone Health, or to the provision of services by Limestone Health
  • To the Department of Corrections, upon request if the Department has determined that you are in need of treatment for mental illness or developmental disability
  • To disclose PHI regarding communicable diseases, as discussed below
  • As necessary to comply with other State or Federal law, including disclosure to the State and/or Federal Department of Health and Human Services as necessary, for a determination that
    Limestone Health is in compliance with the federal privacy standards

Alcohol and Drug Abuse Records: If you receive substance abuse services from Limestone Health, federal law generally requires that Limestone Health cannot disclose PHI that would identify you as a substance abuser or a patient of substance abuse services without your written consent. There are
some exceptions to this requirement. Limestone Health may use or disclose PHI that would identify you as substance abuser or a patient of substance abuse services without your consent or authorization as follows:

  • Within Limestone Health for activities related to the provision of substance abuse diagnosis, treatment, or referral for treatment
  • AS permitted by a court order
  • To medical personnel in a medical emergency
  • To qualified personnel for research, audit, or program evaluation
  • To comply with State law mandating the reporting of suspected child abuse or neglect
  • To communicate with law enforcement personnel about a crime or threatened crime on the premises of Limestone Health or against Limestone Health personnel

Communicable Diseases: If you have one of several specific communicable diseases (for example, tuberculosis, syphilis, or HIV/AIDS), Limestone Health will treat PHI about your disease as confidential and will disclose such PHI without your written consent only in limited circumstances as permitted or required by law. Limestone Health may use or disclose PHI about your disease without your consent or authorization as follows:

  • To health care personnel providing medical care to you
  • As necessary to protect public health
  • As permitted by a subpoena or court order
  • To local or State health directors, upon request
  • As otherwise permitted or required by laws specifically addressing the release of information or records related to HIV/AIDS

Limestone Health may use or disclose PHI about you without your consent in the following circumstance:

Treatment: Limestone Health may use and disclose your PHI to provide, coordinate, or manage your health care and related services, including the disclosure of your PHI to health care providers outside of Limestone Health. For example, Limestone Health may use and disclose your PHI when referring you to another health care provider. Limestone Health also may disclose your PHI to individuals who may be involved in your medical care after you leave Limestone Health. For example, if you are referred to a counselor or psychiatrist for follow-up treatment at Limestone Health.

Payment: Limestone Health may use and disclose your PHI to bill and collect payment for treatment and services provided to you. For example, Limestone Health may share your PHI with your health plan(s) in order to request coverage and obtain approval prior to providing services to you (in nonemergency situations).

Limestone Health may send a bill to you or to third party payor, and this bill may include PHI such as your diagnosis, treatment received, and list of supplied used. Limestone Health may share portions of your PHI, as necessary, with billing departments, collection agencies, insurance companies, and other health care providers.

NOTE: You do have the right to restrict uses and disclosures of PHI to health plans if you have paid for services out of pocket in full.

Health Care Operations: Limestone Health may use and disclose PHI to perform business activities – i.e. “health care operations.” These health care operations enable Limestone Health to improve the quality of care that it provides. For example, members of Limestone Health, medical staff, its risk manager, and other team members may use PHI to assess the care and outcomes in your case, in an effort to continually improve the quality and effectiveness of health care services provided. Limestone Health also may use your PHI in order to provide training programs for its employees resolve grievances within the organization, or review and evaluate the skills and qualifications of health care providers who are treating you.

Minimum Necessary Standard: When using or disclosing your PHI or when requesting your PHI from another entity, Limestone Health will make reasonable efforts not to use, disclose, or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitation. However, the minimum necessary standard will not apply in the following situations:

  • Disclosures to or requests by a health care provider for treatment
  • Uses or disclosures made to you
  • Uses or disclosures made pursuant to an authorization
  • Disclosures made to the Secretary of the US Department of Health and Human Services
  • Uses or disclosures that are required by law
  • Uses or disclosures that are required for Limestone Health’ compliance with legal

Your Rights under the Federal Privacy Standards

Although your health records are the physical property of the healthcare provider who completed them, you have certain rights with regard to the information contained therein.

  1. You have a right to request restrictions on uses and disclosures of your health information by submitting a request in writing. The right to request does not extend to certain uses or disclosures permitted or required by law, such as uses or disclosures for public health activities. In those cases, you do not have the right to request restriction. Limestone Health is not required
    to agree to your requested restriction. However, if Limestone Health does agree to restriction, it will comply with the restriction unless the information is needed to provide emergency treatment to you, or the disclosure is otherwise required under federal regulations.
  2. You have the right to request how and where Limestone Health contacts you about PHI. For example, you may request that Limestone Health contact you at your work address or phone number. Your request must be in writing. Limestone Health is required to accommodate all reasonable requests.
  3. You have the right to obtain a paper copy of this Notice at any time by contacting the facility Privacy Official. Limestone Health will provide a copy of this Notice no later than the date you first receive treatment at the facility, except in emergency situations, and then Limestone Health will provide the Notice to you as soon as reasonable practical after the emergency treatment situation.
  4. You have the right to inspect a copy of your PHI upon submission of a written request. Again, this right is not absolute and in certain situations, Limestone Health can deny access – for example, if a licensed health care professional believes that access to such information could cause harm to your physical or mental well-being.You do not have a right of access to the following:
    • Psychotherapy notes. These include notes that are recorded in any medium by a mental health professional documenting or analyzing a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of your medical record
    • Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings
    • Protected Health Information (PHI) that is subjected to the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”), 42 U.S.C. Section 263a, to the extent that the provision of access to the individual would be prohibited by law
    • Information obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonable likely to reveal the source of the information

    In other situations, the provider may deny you access, but if it does, the provider must provide you with an opportunity to have the denial reviewed by another licensed professional within 60 days of the denial. These “reviewable” grounds for denial include:

    • Licensed healthcare professional has determined, in the exercise of professional judgment, that the access is reasonable likely to endanger the life or physical safety of the individual or another person
    • Protected Health Information makes reference to another person (other than a healthcare provider) and a licensed healthcare provider has determined, in the exercise of professional judgment, that providing access is reasonably likely to cause substantial harm to such other person
    • The request is made by the individual’s personal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that providing access to such personal representative is reasonable likely to cause substantial harm to the individual or another person

    If Limestone Health denies you access to your PHI, Limestone Health will explain why and what your rights are, including how to seek review. If Limestone Health grants you access to you PHI, Limestone Health will give you instructions on any additional steps, if needed, for you to have access to the information. Limestone Health reserves the right to charge a reasonable fee for making copies of the requested PHI.

  5. You have the right to request in writing amendment of your PHI. Limestone Health may deny your request if:
    • Limestone Health did not create the record, unless you provide a reasonable basis to believe the originator of the PHI is no longer available to act on the requested amendment
    • The records are not available for your access, as discussed above in number 4
    • The record is accurate and complete
    • The PHI that is the subject of your request is not maintained by or for Limestone Health

    If Limestone Health denies your request for amendment, Limestone Health will notify you why and how you can submit a written statement disagreeing with the denial (which may be rebutted by Limestone Health) and how you can complain to Limestone Health about the denial. If Limestone Health grants the request, Limestone Health will make the correction and distribute the correction to those who need it and those you identify to Limestone Health that you want to receive the corrected information.

  6. You have the right to obtain an accounting of certain disclosures by Limestone Health of your PHI during the six years prior to the date of your request. However, Limestone Health does not need to provide an accounting for:
    • Disclosures to persons involved in the individual’s care or disclosures for other notification purposes as provided in Section 164.510 of the HIPAA Privacy Rules (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for the care of the individual, of the individual’s location, general condition or death)
    • National security or intelligence purposes under Section 164.512 (k)(2) (disclosures not requiring consent, authorization, or an opportunity to object, see Chapter 16)
    • Correctional institutions or law enforcement officials under Section 164.512 (k)(5) (disclosures not requiring consent, authorization, or an opportunity to object)
    • Disclosures of PHI made prior to the compliance date, April 14, 2003
    • Disclosures of PHI made to carry out treatment, payment or health care operations
    • Disclosures of PHI made to you about your own PHI
    • Disclosures of PHI incidental to a permissible disclosure
    • Disclosures of PHI made pursuant to your written authorization

    Limestone Health must respond to the request for accounting within 60 days of the request by providing the accounting or by granting itself a one-time 30-day extension in which to provide the accounting. The accounting will include:

    • Date of each disclosure
    • Name and address, if know, of the organization or person who received the protected health information
    • Brief statement of the purpose of the disclosure that reasonable informs you of the basis for the disclosure or, in lieu of such statement, a copy of the written request for disclosure where permitted by law

    The first accounting in any 12 month period is free. Thereafter, Limestone Health reserves the right to charge a reasonable retrieval and copying fee.

  7. You have the right to revoke your consent or authorization to use or disclose health information in accordance with the instructions on the consent or authorization form, except to the extent that we have already acted in reliance on the consent or authorization.
  8. Limestone Health is required to notify you and obtain your authorization for the following uses and disclosures:
    • Any uses and disclosures for marketing purposes
    • Any uses and disclosures that constitute the sale of PHI
    • Most uses and disclosures of Psycho Therapy notes (as described in number 4)
    • Other uses and disclosures not described in this notice
  9. Pursuant to 45 C.F.R. 160 and 164;
    You have the right to be notified in the event of a breach of PHI. A “Breach” is defined as “the acquisition, access, use or disclosure of PHI in a manner not permitted under subpart E of this part which compromises the security or privacy of PHI.” Any “acquisition, access, use or disclosure of PHI in a manner not permitted under subpart E is presumed to be a breach unless the covered entity or Business Associate, as applicable, demonstrates that there is a low probability that the PHI has been compromised based on a risk assessment.”

How to Report a Problem

You have the right to complain to Limestone Health by notifying the Privacy Official, #####. Limestone Health will not retaliate against you for filing a complaint. You may also complain to the Secretary of Health and Human Services at 1-877-696-6775, 200 Independence Avenue SW, Washington, DC 20201, if you believe your rights to privacy have been violated.