Sibley Memorial Hospital
Notice of Privacy Practices

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 Sibley’s Privacy Office at 202-537-4667 or PrivacyOffice@Sibley.org.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive at the hospital. 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 the hospital, whether made by hospital personnel or your personal physician or other practitioners involved in your care. Your personal physician may have different policies or notices regarding the doctor’s use and disclosure of your medical information. This Notice also applies to Sibley’s Renaissance Skilled Nursing Unit.

This Notice will tell you about the ways in which we may use and disclose protected health information about you. Protected Health Information ("PHI") is information about you, including demographics, that may identify you and that relate to your past, present or future physical or mental health and related health care services. We also describe your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to:

There are other laws we will follow that provide additional protections, such as laws related to mental health, alcohol and other substance abuse, and HIV/AIDS.

Organized Health Care Arrangement This Hospital and its medical staff members participate in an organized health care arrangement and are presenting you this document as a joint notice applicable to your care at the Hospital. You may presume that this joint notice applies to a medical staff member treating you at the Hospital unless he or she informs you otherwise. The Hospital and its medical staff will share information as necessary to carry out treatment, payment and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect current and future care that we provide to you. Neither this joint notice nor participation in an organized health care arrangement creates an employer-employee or agency relationship between the Hospital and a medical staff member.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose protected health information without your authorization. For each category of uses or disclosures we will explain what we mean and try to give some examples. 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 the categories.

For Treatment We may use protected health information about you to provide you with medical treatment or services. We may disclose protected health information about you to physicians, nurses, technologists, technicians, healthcare students, clergy, or others who are involved in your care. For example, a physician treating you for a hip replacement may need to know if you have diabetes because diabetes may slow the healing process. In addition, the physician may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose protected health information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as rehabilitation facilities or others we or your physician uses to provide services that are part of your care.

For Payment We may use and disclose protected health information about you so that the treatment and services you receive at Sibley may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at Sibley so your health plan will pay us. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your insurance will cover the treatment.

For Health Care Operations We may use and disclose protected health information about you for hospital operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use protected health information to review our treatment and services and to evaluate the hospital’s effectiveness in caring for you or we or our designee may contact you to conduct a patient satisfaction survey.

We may also combine health information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to physicians, nurses, technologists, technicians, healthcare students, and others for review and learning purposes. We may also combine the health information we have with health information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We will remove information that identifies you from this set of health information so others may use it to study health care and health care delivery, while maintaining your privacy.

Appointment Reminders We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital, unless you provide us with alternative instructions.

Treatment Alternatives We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives that may be of
interest to you.

Health-Related Benefits and Services We may use and disclose protected health information to tell you about health related benefits, services, or medical education classes that may be of interest to you.

Fundraising Activities Sibley depends extensively upon private fundraising to advance our health care mission. In our efforts to raise needed funds in support of the hospital, we may use limited information about you (i.e. name, address, and dates of treatment). Information regarding diagnosis and treatment will not be used for fundraising purposes. Any communication sent to you advise you how to opt out of receiving similar communications in the future.

Hospital Directory We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, serious, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also 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. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You may opt out of our hospital directory by notifying us in writing that you do not want your name listed in our patient directory.

Individuals Involved in Your Care or Payment for Your Care We may release health information about you to a friend or family member who is caring for you, unless you ask us not to. However, we may disclose your health information if in our professional judgement it is in your best interest (e.g., medical emergency). We may also give your information to someone who helps pay for your care.

Research We may disclose your health information for medical research that has been approved by our investigational research board, which has evaluated the research proposal and established standards to protect the privacy of your health information. We may disclose your health information to a researcher preparing to conduct a research project.

As Required By Law We will disclose protected health information about you when required to do so by Federal, state or local law. Health information about you may be disclosed to local or Federal health agencies for licensure or certification purposes or the Joint Commission on Accreditation of Health Care Organizations for accreditation purposes.

Incidental disclosures Certain incidental disclosures of your health information may occur as a byproduct of lawful and permitted use and disclosures.

To Avert a Serious Threat to Health & Safety We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent that threat.

SPECIAL SITUATIONS

Organ and Tissue Donation If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks (Health and Safety to you and/or others) We may disclose health information about you for public health activities. We may use and disclose health information about you to agencies when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. These activities generally include the following:

Health Oversight Activities We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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 laws.

Law Enforcement We may release health information if asked to do so by a law enforcement official.

Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose your health information:

Coroners, Medical Examiners and Funeral Directors We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release information to funeral directors as necessary.

National Security and Intelligence Activities We may release health information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Emergencies We may disclose health information in an emergency situation. If we were unable to obtain your consent before treatment was provided,
we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment.

Business Associates We may share health information with third party "business associates" that perform activities for the hospital, subject to a business associates agreement. Whenever an arrangement between the hospital and the business associate involves the disclosure of health information, we will have a written contract that contains terms that require the business associate to appropriately safeguard your health information.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy You have the right to inspect and receive a copy of health information that may be used to make decisions about your care. This includes medical and billing records, but may not include psychotherapy notes.

To inspect and receive a copy of your health information you must submit your authorization in writing to Sibley’s Medical Records Department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We will respond to your request within 30 days.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital 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 Amend If you feel that health information 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 the information is kept by or for the hospital. We will respond within 60 days of receiving your request. Even if we accept your amendment, we will not delete any information already in your records.

To request an amendment, your request must be made in writing and submitted to the Director of Medical Records. In addition, you must provide a reason that supports your request.

We may deny your request if you ask us to amend information that:

Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of protected health information about you to others except for purposes of treatment, payment and operations identified previously.

To request this list or accounting of disclosures, you must submit your request in writing to the Director of Medical Records. We will respond to your request for such a list within 60 days. Your request must state a time period, which may not be 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, within the same 12-month period, 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 at that time before any costs are incurred.

Right to Request Restrictions You have the right to request restrictions on our use or disclosure of your health information. We are not required to agree with your request, but if we do, we will abide by our agreement (except in an emergency). Your request must be made in writing.

Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will try to accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice Notice You have the right to a paper copy of this Privacy Notice. You may ask us to give you a copy of this Privacy Notice at any time.

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 hospital. The notice will contain on the first page, in the top right-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Sibley Memorial Hospital or with the Office for Civil Rights, US Department of Health and Human Services, 150 S. Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-9111. To file a complaint with Sibley, you may call the Sibley hotline at 202-243-2260 or submit your complaint in writing to: Privacy Office, Sibley Memorial Hospital, 5255 Loughboro Road, NW, Washington, DC 20016 or PrivacyOffice@Sibley.org.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.