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
Health Information Services at 881.7220
To obtain a printed copy of this notice - click
Saint Alphonsus Medical Center - Ontario and affiliate Trinity Health facilities
are 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 SAMC Ontario, 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 in SAMC Ontario and with other entities. We also describe your rights and certain
obligations we have regarding the use and disclosure of your health
WILL FOLLOW THIS NOTICE?
Saint Alphonsus Medical Center - Ontario, Dominican Health Services, Sports
and Orthopedic Rehab, Treasure Valley Internal Medicine, Holy
Home Care, Pathway Hospice and Holy Rosary Maternity Clinic.
WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
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 facility or health care personnel who have a
legitimate need for such information in order to take care of you.
Different departments of the facility will share your health information
in order to coordinate the health care services you need, such
as prescriptions, lab work and X-rays. We may disclose your health
information to family members or friends, guardians or personal
representatives who are involved with your medical care. We may
also use and disclose your health information 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. We also may disclose your health information
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, skilled nursing care facilities
and other health care-related services.
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 healthcare entities that have
a relationship with you and need the information for operational
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
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,
clergy can visit you and generally know how you are doing.
You must notify Admitting/Registration Staff at (541)881.7070
orally 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
members of the
public, flower or other service persons and organizations,
and even your friends and family that you are here and your general
We may use your health information, or disclose your health information
to a foundation related to us for SAMC Ontario's
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 our
SAMC Ontario 351 SW 9th St. Ontario, OR 97914 in writing, stating
that you do not want to receive the information.
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.
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
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.
We may release your health information if asked to do so by a law
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
- 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 & FUNERAL
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 to carry out his/her duties.
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
We may disclose your health
information when necessary
to prevent a serious threat
health and safety or the health
of another person or the public.
We may disclose your health
information to federal official(s)
for national security
and for the protection of the
President and other Heads of
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
foreign military personnel
to the appropriate foreign
If you are an inmate of a correctional
institution or in the custody
of a law enforcement official,
we may release your health
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
or the health and safety of
others; or (3) for the safety
and security of the
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.
If you provide us with authorization
to use or disclose
information, you may revoke
that authorization in writing
at any time.
When we receive your written
revocation we will
use or disclose your health
information for the purpose
of that authorization.
However, we are unable to retrieve
any disclosures already
made based upon your prior
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.
You have the following 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,
351 SW 9th St, Ontario, OR 97914, (541) 881.7220. We charge a fee
for document requests to cover the costs of copying, mailing or
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 SAMC Ontario 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
PHI form, and including your reason for the amendment, to the Privacy
Officer or Risk Manager at SAMC Ontario, 351 SW 9th St, Ontario, OR 97914.
Phone # (541) 881.7220
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:
not created by SAMC Ontario; 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 SAMC Ontario;
- 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:
Privacy Officer or Risk Manager at SAMC Ontario
351 SW 9th St,
Ontario, OR 97914.
Phone (541) 881.7220
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 disclosure 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,
351 SW 9th St. Ontario, OR 97914. Phone Number (541) 881.7220.
Your request must state a time period, not longer than six years,
and may not include dates before April 14, 2003. 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
at SAMC Ontario, 351 SW 9th St, Ontario, OR 97914. Phone # (541) 881.7220
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 make your request in writing to Patient Access Staff or
Financial Account Representatives at 351 SW 9th St. Ontario, OR
97914 or to request and submit a “Confidential Communications
Opt Out” form. 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.
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 www.holyrosary-ontario.org. 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.
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 orally or in writing by
contacting the Risk Manager at (541) 881.7022
You will not be penalized for filing a complaint.
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.
If you have agreed to receive this notice electronically, you are still entitled
to a paper copy of this notice
You may print a copy of this notice by clicking the link at the bottom of the
page (Printer Firendly Version). Note: you
will need Acrobat Reader to view and then print this document.
obtain a paper copy of this notice, contact: Patient
Saint Alphonsus Medical Center - Ontario
351 SW 9th St
Ontario, OR 97914.
Phone: (541) 881.7000
you wish to print this document, click the link below. You
will need Acrobat Reader to view and print the document. If
you do not have it installed on your PC, click this link:
Acrobat Reader - Free Download
Friendly Version (click this link to open the document
in Adobe Acrobat)
a phone number for any hospital department
of Privacy Practices:
Notice of Privacy Practices
U.S. Department of Health & Human
Privacy - National Standards to Protect the Privacy of Personal