HIPAA / Privacy Policy
Notice of Privacy Practices for Shell Rock Family Health.
Introduction
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.
We are required by federal law to maintain the privacy of your medical information and to give you our Notice of
Privacy Practices (this “Notice”) that describes our privacy practices, our legal duties and your rights concerning your
medical information. This Notice applies to Shell Rock Family Health. This Notice applies to and will be followed by: (1)
all employees, staff, volunteers and other personnel, and (2) the physicians and other practitioners who are not
employed by the Facility, but who have privileges to treat patients.
How We May Use and Disclose
Your Medical Information
Except where such use or disclosure is otherwise prohibited by state or federal law, the Facility is permitted or required
to use or disclose your medical information without your authorization (permission) in the following situations. Some,
but not all, specific examples of the different types of disclosures have been listed.
• Treatment. To provide you with medical treatment or services (e.g., provide information to doctors, nurses,
technicians, students or other personnel who are involved in your care).
• Payment. To collect payment from you, an insurance company or a third party for the treatment and services you
receive (e.g., submitting a claim to your insurance company).
• HealthCare Operations. For Facility healthcare operations (e.g., to evaluate our staff and internal processes). As
part of the Facility’s healthcare operations, certain limited information may be used or disclosed to conduct fund raising
activities on behalf of the Facility. You have the right to request that you not receive fund raising materials from the
Facility.
• Appointments and HealthCare Services. To provide you with appointment reminders or to notify you of possible
treatment alternatives or health-related benefits or services.
• Friends and Family. To a friend or family member involved in your medical care or payment for your care. If you
are available, such disclosures will be made only if we have obtained your permission, if you do not object to the
disclosure after having the opportunity, or if it is reasonable for us, based on the circumstances, to assume you have
no objection to such disclosure. If you are unavailable, incapacitated or in an emergency situation, the Facility may
disclose limited information to these persons if the Facility determines disclosure is in your best interest.
• HealthCare Providers. To another healthcare provider involved in your treatment in order for that provider to
treat you, bill for its services and conduct certain of its healthcare operations.
• Disaster Relief. To a public or private entity assisting in a disaster relief effort (e.g., to notify your family about
your location, condition or death).
• Public Health Activities. To public health authorities for public health activities as permitted or required by law (e.
g., to report births, deaths, child abuse and neglect, immunizations and communicable diseases).
• Abuse, Neglect and Domestic Violence. The Facility may notify the appropriate government authority if it believes
you have been the victim of abuse, neglect or domestic violence. Unless such disclosure is required by law, the Facility
will only make this disclosure if you agree or under other limited circumstances when such disclosure is authorized by
law.
• Health Safety Risks. Under certain circumstances, when necessary to prevent a serious threat to your health and
safety or to the health and safety of the public or another person.
• Organ Donations. To organ procurement or organ, eye or tissue transplantation organizations, or to organ
donation banks to facilitate organ or tissue donation and transplantation.
• Military and National Security. If you are a member of the armed forces, as required by military command
authorities. We may also release medical information about foreign military personnel to the appropriate foreign military
authority. The Facility may also release your medical information to authorized federal officials for intelligence,
counterintelligence, and other authorized national security activities.
• Worker’s Compensation. To persons (e.g., employers, insurance carriers, attorneys) in order to comply with
workers’ compensation laws or other similar programs providing benefits for work-related injuries.
• Health Oversight Activities. To a health oversight agency for activities authorized by law to monitor the healthcare
system, government programs and compliance with civil rights laws (e.g., fraud and abuse investigations, inspections
and licenser, or disciplinary actions).
• Legal Proceedings. If you are involved in a lawsuit or dispute, in response to a court or administrative order. The
Facility may also disclose medical information about you in response to a subpoena or other lawful process by
someone else involved in the dispute, but only if the party seeking the information demonstrates that reasonable
efforts have been made to notify you of the request or to obtain a protective order from the court.
• Law Enforcement. To law enforcement authorities for law enforcement purposes, such as (1) in response to a
court order, subpoena, warrant, summons or similar process, (2) to identify or locate a suspect, fugitive, material
witness or missing person, (3) if you are the victim of a crime, but only if your agreement is obtained or in response to
a subpoena, (4) about a death which is believed to be the result of criminal conduct, (5) to report a crime that occurred
on Facility premises, and (6) 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. The Facility must comply with federal and state
laws in making such disclosures.
• Deceased Individuals. To a coroner or medical examiner as necessary to carry out their duties (e.g., to identify a
deceased person or determine the cause of death), or to funeral directors as authorized by law.
• Correctional Institutions. To a correctional institution where you are an inmate or to a law enforcement official
who has custody of you for certain limited purposes (e.g., to provide you with healthcare).
• Research. For research-related activities that meet all privacy law requirements. Limited Medical Information.
Limited medical information to a third party for research purposes, public health activities and Facility healthcare
operations. The party to whom we disclose the information is required to keep it confidential.
• Required by Law. When required to do so by federal, state or local law (e.g., to report child or dependent adult
abuse and violent wounds).
• Incidental Disclosures. Occasional incidental, unintended disclosures of your medical information which might
occur during a permitted use or disclosure (e.g., information overheard during a discussion regarding your care with
you or a member of your family). We will take reasonable steps to avoid these types of disclosures.
• Business Associates. Some of the activities described above are performed through contracts with outside
persons or organizations, such as legal services. It may be necessary for the Facility to provide some of your medical
information to outside business associates who assist the Facility with these activities. The Facility requires that its
business associates appropriately safeguard the privacy of your information.
• Organized HealthCare Arrangement. The Facility is a clinically integrated care setting where patients receive
care from Facility personnel and from independent doctors and other practitioners who provide care to patients at the
Facility (collectively called “practitioners”). The Facility and these practitioners need to share medical information freely
to provide care to patients, and to conduct Facility healthcare operations. Therefore, the Facility and the practitioners
have agreed to follow uniform information practices when using or disclosing medical information related to inpatient or
outpatient hospital services. This arrangement is called an “organized healthcare arrangement” and only covers
information practices for services rendered through the Facility. It does not cover the information practices of the
practitioners in their offices or at other care settings. It does not alter the independent status of the Facility and the
practitioners or make them jointly responsible for the clinical services provided by them. In other words, the Facility is
not responsible for (1) the negligence (or mistakes) of the independent practitioners providing care at the Facility; or
(2) any violations of your privacy rights by the independent practitioners.
Your Rights
• You and Your Authorization. The Facility must also disclose your medical information to you, as described later in
this Notice. Uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be
made only with your written permission. If you give us permission to use or disclose medical information about you, you
may revoke (take back) that permission, in writing, at any time. If you revoke your permission, we will no longer use or
disclose medical information about you for the reasons set forth in your written authorization. We are unable to take
back any disclosures we have already made with your permission.
• Access to Medical Information. You may request to inspect and copy much of the medical information we maintain
about you, with some exceptions. This includes most medical and billing records, but does not include psychotherapy
notes. We may charge a fee for the costs of copying, mailing, and other supplies associated with your request.
• Request for Restrictions. You have the right to request a restriction on how we use or disclose your medical
information for treatment, payment, or healthcare operations, or to certain family members or friends identified by you
who are involved in your care or the payment for your care. We are not required to agree to your request, but will
notify you if we are unable to agree.
• Amendment. You may request that we amend certain portions of your medical information if you believe that it is
incorrect or incomplete. We may require you to give a reason to support your request. We are not required to make all
requested amendments, but we will give each request careful consideration. If we deny your request, we will provide
you with a written explanation of the reasons and your rights.
• Accounting. You have the right to receive a list of certain disclosures of your medical information made by us or
our business associates. You must state a time period for your request, which may not be longer than six years and
may not include dates before April 14, 2003. The first list in any 12-month period will be provided to you for free; you
may be charged a fee for each subsequent list you request within the same 12-month period.
• Confidential Communications. You have the right to request that we communicate with you about medical matters
in a different manner or at a different place. We will agree to your request if it is reasonable, and you specify an
alternative means or location to contact you.
• Paper Notice. You are entitled to receive a written copy of this Notice at any time.
How to Exercise These Rights
All requests to exercise these rights must be in writing. We will follow written policies to handle requests, and we will
notify you of our decision or actions and your rights. Contact the office manager, at the contact information at the end
of this Notice for more information or to obtain request forms.
Complaints
If you believe your privacy rights have been violated; you may file a complaint with the Facility using the contact
information at the end of this Notice. You may also submit a complaint to the Secretary of the Department of Health and
Human Services. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a
complaint.
Questions
If you have questions about this Notice, please contact the office manager at the contact information at the end of this
Notice.
About This Notice
The Facility is required to abide by the terms of the Notice currently in effect. The Facility reserves the right to change
the terms of this Notice and make the new Notice provisions effective for all of your medical information that it
maintains, including that which it created or received while the prior Notice was in effect. If the Facility makes a material
change to its privacy practices, it will amend its Notice. We will post a copy of the current Notice in the Facility. The
Notice will state the effective date
Office Manager
Shell Rock Family Health
PO Box 665
Shell Rock, IA 50670
Call: (319) 885-6530
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INTERNET PRIVACY
Collecting and Using Personal Information
Welcome to Shell Rock Family Health’s website. We appreciate your interest in us! When you visit and navigate our
sites and when you communicate with us via our website, we will not collect personal information about you unless you
provide us that information voluntarily. If you provide personal information to us voluntarily via our website, we will not
sell, license or transmit that information outside of Shell Rock Family Health. We will disclose information in compliance
with applicable laws and regulations and will require recipients to protect the information and use it only for the purpose
provided.
By “personal information,” we mean data that is unique to an individual, such as a name, address, social security
number or telephone number. We may request personal information from you at our site in order to deliver requested
materials to you, respond to your questions or deliver a product or service.
E-Mail and Asking Questions
First of all, it is important that you realize that any online health services and health information is not intended as a
substitute for direct information from a trained medical professional, such as a physician, nurse or caregiver. You
should always consult directly with a medical professional for diagnosis and treatment of any specific health problems
or immediate health concerns. The information on our website is not medical advice!
Please note that your e-mail, like most, if not all, non-encrypted Internet e-mail communications, may be accessed and
viewed by other Internet users, without your knowledge and permission, while in transit to us. For that reason, to
protect your privacy, please do not use e-mail to communicate information to us that you consider confidential. If you
wish, you may contact us instead via telephone at the numbers provided.
Linking to Other Sites
From time to time our website may provide links to other websites, not owned or controlled by Shell Rock Family Health
that we think might be useful or of interest to you. We cannot, however, be responsible for the privacy practices used
by other website owners or the content or accuracy of those other websites. Links to various outside websites do not
constitute or imply endorsement by Shell Rock Family Health of these websites, any products or services described on
these sites, or of any other material contained in them.
Changes to This Statement
Shell Rock Family Health may change this statement from time to time without notice. We plan to post notice on our
home page for no less than a week if any significant changes occur. This privacy statement is not intended to and
does not create any contractual or other legal rights in or on behalf of any party.