2255 S. 88th St. Louisville, Colorado 80027 • Phone 303.673.9990 • Fax 303.673.9703
NOTICE OF PRIVACY PRACTICES
Centennial Peaks Hospital

Effective Date: April 14, 2003


THIS NOTICE DESCRIBES HOW HEALTH INFORMATION (MEDICAL, PSYCHOLOGICAL, DRUG, AND ALCOHOL) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.


PURPOSE

We, Centennial Peaks Hospital (CPH), are required by law to maintain the privacy of Protected Health Information (PHI) and to provide individuals with notice of our legal duties and privacy practices (with respect to PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA). This Notice is yours. CPH shall abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI maintained. You may obtain a copy of the current Notice upon request. If you are a current patient and the Notice changes, you will receive an updated Notice during your stay.


USES AND DISCLOSURES

Your Protected Health Information (PHI) may be used by Centennial Peaks Hospital (CPH) for the purpose of Treatment, Payment and Healthcare Operations (TPO).

FOR EXAMPLE:

For the purpose of treatment: Healthcare providers such as psychiatrists, psychologist, and social workers, at CPH may share health information amongst CPH staff to develop and carry out your treatment plan. If you are referred here by a professional, we will acknowledge your presence here as applicable.

For the purpose of payment: The Business Office may contact your listed insurance provider or emergency contact for certification/verification of insurance benefits.

In addition, if you are a member of a group health plan, or individual policy such as an HMO or PPO, the mental health management company may request CPH to release PHI to the medical health plan. CPH will honor the request unless the patient or representative notifies us otherwise.

For Healthcare Operations: Medical, Nursing and Social Work students may participate in the treatment process as permitted by the Administration at CPH. In the event of a death, communication with the Medical Examiner and/or Coroner’s Office is required.


Please refer to our Inpatient or Outpatient Voluntary Consent form for additional information regarding TPO.

If you are an Involuntary Patient, you have been admitted to our facility due to a medical emergency as defined by 42 C.F.R. 2.51(a), 27-10-105, or any other emergency procedure applicable. In this case, patient identifying information may be disclosed to medical personnel who have a need for information about a patient for the purpose of treating a condition which poses an immediate threat to the health of any individual and which requires immediate medical intervention. Our licensed professionals may request information regarding treatment as applicable for the emergency.


YOUR RIGHTS

Under HIPAA you have the right to request restriction on certain uses and disclosures of your health information. CPH is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use to disclose such information except as necessary in a medical emergency or by court order. You have the right to confidential communication. You may request that we communicate with you by alternative means or at an alternative location, such as a Post Office box. CPH will accommodate such requests that are reasonable. Under HIPAA you also have the right to inspect and receive a copy of your own health information maintained by CPH, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances. Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in CPH’s records, and to request and receive an accounting of disclosures of your health related information made by CHP during the six years prior to your request. (Please note that the accounting requirement becomes effective (4-14-03). You have the right to receive a paper copy of this Notice upon request.


WHAT IF MY HEALTH INFORMATION NEEDS TO GO SOMEWHERE ELSE?

You may request that CPH send your health information somewhere. An "Authorization to Release/Request Information" or equivalent must be completed. The authorization form tells us what, where and to whom the information must be sent. Your authorization is valid for ninety (90) days or until the date you state on the form. You can cancel or limit the amount of information sent at any time by letting us know in writing.

If you are less than 18 years old – your parents or guardians may receive your private health information and are considered your legal representative, unless by law you are able to consent for your own health care treatment. If you are, then your private health information will not be shared with parents or guardians unless you sign an authorization form. If you are emancipated or are able to seek treatment on your own and desire to limit authorization for the release of information, please notify the admissions’ staff or the physician.


COULD MY HEALTH INFORMATION BE RELEASED WITHOUT MY AUTHORIZATION?

When private health information is released without an authorization, it is normally used for Treatment, Payment or Operations (managing the business of a health care provider and reporting to agencies that oversee our business, such as state regulators). The release of health information for this purpose is not tracked and we are not accountable to you for it. Any other release made without your authorization is tracked and accounted for. We report:
 
  1. To any government agency that oversees our business
     
  2. Reactions and problems with medicine
     
  3. Victims of abuse, neglect or domestic violence
     
  4. To any agency with jurisdiction to inquire about our business
     
  5. To prevent serious threat to your or others’ health and safety
     
  6. Work-related injuries
     
  7. Out of state offenders
     
  8. As required by court order and/or subpoena
     
  9. If you commit a crime on the premises


HOW CAN I FIND OUT IF MY HEALTH INFORMATION HAS BEEN RELEASED WITHOUT MY AUTHORIZATION?

To find out if your health information has been released without your authorization for purposes other than Treatment, Payment or Operations, contact the Health Information Department at Centennial Peaks Hospital and ask for "A Request for Accounting of Disclosures" form. Simply fill out the form, attach a copy of your most recent picture ID, and send both to:


Centennial Peaks Hospital, Health Information, 2255 South 88th Street, Louisville, CO 80027.


QUESTIONS OR COMPLAINTS?

If you have questions about this notice or would like to file a complaint stating that your privacy rights have been violated, please contact: The Patient Advocate or Privacy Officer at Centennial Peaks Hospital: (303) 673-9990. There is no retaliation for filing a complaint. You may also file a complaint with the Secretary of Health and Human Services.