PROMEDICA HEALTH SYSTEM, INC.

CORPORATE HIPAA POLICY

Policy Title:  Dissemination of the Notice of Privacy Practices (“Notice”)    

Effective Date: April 14, 2003

Purpose: The federal HIPAA regulations on patient privacy and confidentiality require ProMedica Health System (“PHS”) entities to provide notice to patients and the public about how personal health information may be used and disclosed by the organization. 

1. Timing of Provision. The Notice must be made available, distributed, and the appropriate signage posted at each PHS entity in accordance with this policy on or before April 14, 2003. 

2. Availability to the Public. A copy of the Notice must be made available on request to any person who requests it in each separate building where patients receive treatment. A copy of this Notice can be requested from the contact person listed in Section VII of the Notice, and can be viewed on the PHS web site at www.promedica.org.

Individuals have the right to receive a copy of this Notice by e-mail and to request a paper copy. Individuals that cannot read may request that an employee read the Notice to the individual upon appointment.

3. Distribution to Patients. All patients will be offered a copy of the Notice no later than the date of the first service delivery or first treatment encounter on or after April 14, 2003, including service delivered electronically, to such patient. Each PHS entity will make a good faith effort to obtain written acknowledgment or receipt of the Notice by having the patient or legally authorized representative initial the respective section of the standard PHS Consent for Treatment or a similar acknowledgment form. The Notice will remain valid until such time that the notice has been revised.

In accordance with PHS policy CP 6.01, before the first treatment, and prior to the initiation of each episode of care at all PHS entities, patients must sign the PHS Consent for Treatment and be  provided with a Notice. Physician office practices, clinic settings, and other such similar entities will perform this function annually upon presentation for treatment.In an emergency situation, the Notice should be provided and acknowledgment obtained as soon as reasonably practicable after the emergency situation.  

When the first treatment encounter for a direct treatment relationship with the patient is over the telephone, the Notice will be forwarded to the individual that day unless the first face-to-face encounter with the patient will occur shortly thereafter. The notice may be forwarded via mail, fax, or e-mail and documentation of that fact shall be maintained for a period of six years. The written acknowledgment will be obtained at the first face-to-face encounter with the patient or earlier in accordance with individual PHS entity policy.

Scheduling an appointment is not considered a treatment encounter. As such, the Notice will be provided to the patient at the time the individual arrives at the PHS entity for his or her appointment.
 
If acknowledgment of the Notice cannot be obtained, the good faith efforts to obtain the acknowledgment and the reasons why the acknowledgment was not obtained must be documented on the PHS Consent for Treatment form or similar acknowledgment form and retained in the medical record.

4. Inmates.  When the patient is an inmate in a correctional facility, provision of the Notice and the attempt to obtain acknowledgment of receipt of the Notice is not required.

5. Signage.  Each PHS entity is required to post the Notice in all buildings where patients receive treatment. Notice signage for all PHS entities is developed and obtained through PHS Public Relations.

6. E-mail Delivery of Notice. The Notice may be provided to a patient by e-mail, if the patient agrees to electronic notice. An electronic acknowledgment from the patient via e-mail will be considered written acknowledgment of receipt. Such e-mail message will be printed and retained in the medical record. If it is known that the e-mail transmission failed, a paper copy of the Notice must be provided to the patient.

7. Web Site Posting. A copy of the most recent Notice will be posted prominently on the PHS web site, for each individual PHS entity.

8. Revisions to the Notice. PHS reserves the right to change its Notice and privacy policies at any time. Any changes will apply to all protected health information. If any changes are made to PHS privacy policies, the Notice will be changed, if applicable, and a new Notice will be posted on the PHS web site.

9. Record Retention.  The individual Privacy Officer at each entity shall retain all versions of the Notice, i.e., the original and all subsequent revised Notices. Copies of the Notices shall be retained for six years.