EFFECTIVE SEPTEMBER 23, 2013
The following 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 these notices, please contact the appropriate Privacy Officer or Compliance Department at (701) 857-3400.
Notice of Privacy Practices
This Notice describes our healthcare provider’s practices and that of:
- Any healthcare professional authorized to enter information into your medical record.
- Any department and unit of the facility.
- Any member of a volunteer group we allow to help you while you are in the facility or after you are discharged.
- All employees, staff and other healthcare provider personnel including all medical staff members while providing services in the facilities.
- This Notice applies to all of the facilities listed at the end of this document. In addition, these entities, sites and locations may share protected health information with each other for treatment, payment or healthcare operations purposes described in this Notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We create a record of the care and services you receive at the facility. 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 this Covered Entity. Other caregivers, if not employed by Trinity, may have different policies or notices regarding their use and disclosure of your medical information created in their office or clinic.
This Notice will tell you about the ways in which we may use and disclose information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of information.
We are required by law to:
- make sure that information that identifies you is kept confidential;
- give you this notice of our legal duties and privacy practices with respect to information about you; and
- follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For each category we will explain our intent and give an example.
USE AND DISCLOSURE WITHOUT AUTHORIZATION
Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.
We may use health information about you to provide you with medical treatment or services and to coordinate and manage your care. We may disclose PHI about you to doctors, nurses, technicians, students in healthcare training programs, or other personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because of its potential effect on the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of Trinity may share health information about you in order to coordinate the services you need, such as prescriptions, lab work and x-rays. We may disclose health information about you to people outside Trinity who provide your medical care, such as nursing homes or other doctors.
We may use and disclose information about you and the treatment and services you receive in order to obtain payment for such treatment and services. For example, we may use and disclose PHI to send bills and collect payment from you, your insurance company, or other payers, such as Medicare, for the care, treatment, and other related services you receive. We may tell your health insurer about a treatment your doctor has recommended to obtain prior approval to determine whether your plan will cover the cost of the treatment.
FOR HEALTH CARE OPERATIONS:
We may use and disclose PHI about you for the purpose of our healthcare operations, which are necessary to run Trinity and ensure that our patients receive quality care and cost effective services. For example, we may use PHI to review the quality of our treatment and services, and to evaluate the performance of our staff, contracted employees and students in caring for you.
We may use or disclose your PHI to outside individuals or entities that assist us in operating our health system (our “business associates”) and that need information about you so that they can provide services to us. Examples of Trinity’s business associates include, but are not limited to, Trinity’s auditors, accreditation organizations, attorneys and consultants. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to re-disclose the information unless specifically permitted by law.
FAMILY MEMBERS, FRIENDS AND OTHERS ASSISTING IN YOUR CARE:
If you agree, do not object, or we reasonably infer that there is no objection, and to the extent permitted by law, we may disclose PHI about you to a family member, relative, or another person identified by you who is involved in your healthcare or payment for your healthcare. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited PHI is in your best interest under the circumstances. We may disclose PHI to a family member, relative, or another person who was involved in the healthcare or payment for healthcare of a deceased individual if not inconsistent with the prior expressed preferences of the individual that are known to Trinity.
We may use and disclose PHI to contact you for appointment reminders and to communicate necessary information about your appointment. We may also send you refill reminders or other communications about your current medications. However, if we receive any financial remuneration for making such refill or medication communications beyond our costs of making the communication, we must first obtain your written authorization to make such communications.
TREATMENT ALTERNATIVES AND OTHER SERVICES:
We may contact you about treatment alternatives or other health benefits or services that might be of interest to you. We may contact you with information about new or alternative treatments or other healthcare services or for purposes of care coordination, unless we receive financial remuneration in exchange for making the communication; in that case, we will obtain your written authorization to make such communications. However, we are not required to obtain your written authorization for face-to-face communications.
When you are admitted to the hospital or nursing home, Trinity may list certain limited information about you, such as your name, your location in the facility, a general description of your condition that does not communicate specific medical information, and your religious affiliation (if you provide this information to us), in a facility directory. The facility can disclose this information, except for your religious affiliation and your condition, to people who ask for you by name. This is so your family, friends and clergy can know your location. Your religious affiliation may be given to members of the clergy even if they do not ask for you by name. You may request that no information contained in the directory be disclosed. To restrict use of information listed in the directory, please notify the Privacy Officer (contact information below). In emergency circumstances, if you are unable to communicate your preference, you will be listed in the directory if such inclusion is not inconsistent with your prior expressed preference and it is in your best interest, as determined by your healthcare practitioner in his/her professional judgment.
We may use certain PHI about you (specifically, your name, address, gender, date of birth and other demographic information; the dates you received services from Trinity; the department from which you received service; your treating physician; outcome information; and health insurance status) to contact you to raise money for Trinity interests. We may share this information with a foundation associated with Trinity to work on our behalf. Each fundraising communication you receive will include an opportunity to opt-out of future fundraising communications. Alternatively, you may call or email the Trinity Foundation at 701-857-2430, or [email protected] to opt-out of fundraising communications.
REQUIRED OR PERMITTED BY LAW:
We may use or disclose your PHI when required or permitted to do so by federal, state, or local law.
PUBLIC HEALTH ACTIVITIES:
We may use or disclose your PHI for public health activities that are permitted or required by law. For example, when required or permitted by law, we may disclose your PHI in certain circumstances to control or prevent a communicable disease, injury or disability; to report births and deaths; to report abuse or neglect of a vulnerable adult; and for public health oversight activities or interventions. We may disclose your PHI to the Food and Drug Administration (“FDA”) to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law or to a state or federal government agency to facilitate their functions. We also may disclose PHI, if directed by a public health authority, to a foreign government agency that is collaborating with the public health authority.
HEALTH OVERSIGHT ACTIVITIES:
We may disclose PHI about you to a health oversight agency for activities authorized by law. For example, these oversight activities may include government audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, other government regulatory programs, and government agencies that ensure compliance with civil rights laws.
LAWSUITS AND OTHER LEGAL PROCEEDINGS:
We may disclose your PHI in the course of a judicial or administrative proceeding in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized). If certain conditions are met, we may also disclose your protected health information in response to certain types of subpoena, discovery requests, or other lawful process. We may disclose PHI in the context of civil litigation where you have put your condition at issue in the litigation.
Under certain conditions, we also may disclose certain PHI to law enforcement officials for law enforcement purposes. These law enforcement purposes include, by way of example, (1) responding to a court order, court-ordered warrant, a subpoena or summons issued by a judicial officer, a grand jury subpoena or an administrative subpoena, summons or other process that meets certain requirements; (2) as necessary to locate or identify a suspect, fugitive, material witness, or missing person; (3) reporting suspicious wounds, burns or other physical injuries; or (4) as relating to the victim of a crime, in certain circumstances.
TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY:
Consistent with applicable laws, we may disclose PHI about you if disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We also may disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES:
We will release PHI about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities only as required by law or with your written consent.
PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS:
We will disclose PHI 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 only as required by law or with your written consent.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we will release PHI about you to the correctional institution or law enforcement official only as permitted by law.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS:
We may release PHI about you to a coroner or medical examiner in the case of certain types of death. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release PHI about you to a funeral director, as necessary, to carry out his/her duties.
ORGAN, EYE AND TISSUE DONATION:
We will disclose certain limited PHI to organizations that obtain, bank or transplant organs or tissues when necessary to make a transplant or donation possible.
Trinity may use and share your health information for certain kinds of research. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. Prior to disclosing PHI about you for research purposes, Trinity will obtain your written authorization or will ensure that the research study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins. In some cases, researchers may be permitted to use information in a limited way to determine whether the study or the potential participants are appropriate.
We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
MILITARY AND VETERANS:
If you are a member of the armed forces, we will release medical information about you as requested by military command authorities if we are required to do so by law or when we have your written consent. We may also release medical information about foreign military personnel to the appropriate foreign military authority as required by law or with written consent.
SHARED MEDICAL RECORD/HEALTH INFORMATION EXCHANGES:
We maintain PHI about our patients in shared electronic medical records that allow Trinity and its affiliates to share PHI for treatment and healthcare operations purposes. We may also participate in various electronic health information exchanges that facilitate access to PHI by other healthcare providers who provide you care. For example, if you are admitted on an emergency basis to another hospital that participates in the health information exchange, the exchange will allow us to make your PHI available electronically to those who need it to treat you. You may opt out of sharing your PHI by signing the “opt-out” form supplied by Trinity.
OTHER USES AND DISCLOSURES OF PHI
Most uses and disclosures of PHI for marketing purposes and disclosures that constitute the sale of PHI require your written authorization. Other uses and disclosures of your PHI that are not described in this Notice will be made only with your written authorization. If you provide Trinity with an authorization, you may revoke the authorization in writing, and the revocation will be effective for future uses and disclosures of PHI. However, the revocation will not be effective for information that we have used or disclosed in reliance on the authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.
YOU HAVE THE FOLLOWING RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU THAT WE MAINTAIN:
THE RIGHT TO INSPECT AND COPY:
You have the right to inspect and receive a copy of the PHI that is maintained as medical and billing records by Trinity Health for as long as we maintain it as required by law. All requests for access must be made in writing and provided to the Health Information/Medical Records Department at:
- Trinity Hospitals or Trinity Medical Group: 407 3rd Street SE, Minot, ND or, if by mail, PO Box 5020, Minot, ND 58702-5020, (701) 857-5390
- Trinity Homes: 305 8th Avenue N.E. Minot, ND or, if by mail, PO Box 5030, Minot ND 58702-5030, (701) 857-5817
- Trinity Health Kenmare Hospital: 317 1st Avenue NW, Kenmare, ND or, if by mail, PO Box 697, Kenmare, ND 58746-0697, (701) 385-4296
- Trinity Health Riverside Outpatient Behavioral Health: 1900 8th Avenue SE, Minot, ND 58701, (701) 857-5998
- First Response Ground/Air Transport (formerly known as Community Ambulance and NorthStar Criticair): 407 3rd Street SE, Minot, ND or, if by mail, PO Box 5020, Minot, ND 58702-5020, (701) 857-5390
If you request a copy of your PHI, or a summary, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request, to the extent permitted by state and federal law. If we maintain PHI about you electronically as part of a designated record set, you have the right to receive a copy of your health information in electronic format upon your request. You may also direct us to transmit your PHI (whether in hard copy or electronic form) directly to an entity or person clearly and specifically designated by you in writing. We may deny your request to inspect and copy your PHI in certain very limited circumstances. For example, we may deny access to psychotherapy notes or when a certain law prohibits your access, or if your physician believes it will be harmful to your health, or could cause a threat to others. In these cases, we may supply the PHI to a third party who may release the information to you. If you are denied access to PHI, you may request that the denial be reviewed. Another licensed healthcare professional chosen by Trinity will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
RIGHT TO REQUEST RESTRICTIONS:
You have the right to request certain restrictions of our use or disclosure of your PHI. Trinity will agree to restrict disclosure of PHI about an individual to a health plan if the purpose of the disclosure is to carry out payment or healthcare operations and the PHI pertains solely to a service for which the individual, or a person other than the health plan, has paid Trinity for in full. For example, if a patient pays for a service completely out of pocket and asks Trinity not to tell his/her insurance company about it, we will abide by this request. However, we are not required to agree with any other request. If Trinity agrees to the restriction, we will comply with your request unless the information is needed to provide you emergency treatment. A request for restriction should be made in writing to the respective facility’s Privacy Officer (contact information below). You must tell us (1) what PHI 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, if you want to prohibit disclosures to your spouse. We reserve the right to terminate any previously agreed-to restrictions (other than a restriction we are required to agree to by law). We will inform you of the termination of the agreed-to restriction and such termination will only be effective with respect to PHI created after we inform you of the termination.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS:
You have the right to request that we communicate with you in an alternative manner or at an alternative location. For example, you may ask that all communications be sent to your work address. Your written request must be made to the Privacy Officer (contact information below) and must specify the alternative means or location for communication with you; we may require you to provide information about how payment may be handled. We will accommodate all reasonable requests.
RIGHT TO REQUEST AN AMENDMENT:
If you feel that PHI 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 Trinity maintains the PHI. Requests for amending your PHI must be in writing and made to the respective facility’s Privacy Officer (contact information below). Your request must include a reason that supports your request for amendment. We may deny your request 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 Trinity, is not part of the PHI kept by or for Trinity, is not part of the information which you would be permitted to inspect or copy or is accurate and complete. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.
RIGHT TO AN ACCOUNTING:
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of PHI about you. This list will not include disclosures for treatment, payment, and healthcare operations; disclosures that you have authorized or that have been made to you; disclosures for facility directories; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement with custody of you; disclosures that took place before April 14, 2003; and certain other disclosures. To request this list of disclosures, you must submit your request in writing to the Privacy Officer (contact information below). Your request must state a time period for which you would like the accounting. The accounting period may not go back further than six years from the date of the request, and it may not include dates before April 14, 2003. You may receive one free accounting in any 12-month period. We will charge you for additional requests.
RIGHT TO A PAPER COPY OF THIS NOTICE:
You have the right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice any time.
If you believe your rights under HIPAA have been violated, you may file a written complaint with the respective facility’s Privacy Officer (contact information below), or the Corporate Compliance Department at 701-857-3400 (Compliance Hotline) or PO Box 5020, Minot, ND 58702-5020. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint.
CHANGES TO THIS NOTICE:
The effective date of this Notice is April 14, 2003, and it has been updated effective September 23, 2013. We reserve the right to change this Notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you, as well as any information we receive in the future. If the terms of this notice are changed, Trinity will provide you with a revised notice upon request, and we will post the revised Notice on our website at: https://www.trinityhealth.org/
Unless otherwise specified, to exercise any of the rights described in this Notice, to receive more information about this Notice, or to file a complaint, please contact the Privacy Officer at 701-857-5207 (Trinity Hospitals); 701-857-5801 (Trinity Homes); 701-418-7580 (Trinity Medical Group); 701-418-7675 (Trinity Health Kenmare Hospital).
The mailing address is PO Box 5020, Minot, ND 58702-5020.
THIS NOTICE APPLIES TO THE FOLLOWING COVERED ENTITIES:
- Trinity Health
- Trinity Hospitals
- Trinity Medical Group and Affiliates
- Trinity Homes
- Trinity Health Kenmare Hospital
- All Facilities and Services Bearing the Trinity Health Logo