Patient Privacy Forms Packet

Click here to download the packet of Patient Privacy Forms.

Patient Privacy Policy, Practices & Procedures

Click here to download the following:
1. Patient Privacy Policy
2. Statement of Privacy Practices
3. Health Center Patient Privacy Procedures

POLICY: HI001 HIPAA & Patient Privacy Policy

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS
APPROVED BY THE BOARD OF DIRECTORS AT THE MAY 2015 BOARD MEETING

It is the policy of HOPE Family Health to adopt and implement legally sound and fully compliant (with both federal and state laws) procedures by which to govern the access, use, disclosure, dissemination, storage, and sharing of our patient’s protected health information and medical and behavioral healthcare records in an integrated medical/primary and behavioral healthcare environment. The board appointed Chief Compliance Officer shall also serve as the health center’s Privacy Officer, whose responsibility is to ensure that minimum necessary disclosure is occurring at all times when HFH employees, contractors, and/or agents are interacting with Protected Health Information. It is also the responsibility of the Privacy Officer to thoroughly investigate any instances of breach of privacy or any reports thereof.

POLICY: HI002 Statement of Privacy Practices

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS
APPROVED BY THE BOARD OF DIRECTORS AT THE MAY 2015 BOARD MEETING

This Statement of Practices and included procedures comply with all federal HIPAA laws as well as the laws and regulations of the State of Tennessee that govern patient privacy and healthcare information disclosures in an integrated medical/primary and behavioral healthcare environment. This Statement of Privacy Practices should be made available to every patient and HFH shall make every reasonable attempt to address any questions or concerns any patient has regarding HFH’s Privacy Practices or Procedures. Privacy Practices and Procedures should be updated when changes are made to federal and state laws that govern such practices.

PROCEDURE: HI002 Statement of Privacy Practices

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU AS THE PATIENT MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND IN FULL AND UNDERSTAND THAT BY SIGNING THE ACKNOWLEDGEMENT CONTAINED IN THIS DOCUMENT, YOU ARE AGREEING TO GIVE HOPE FAMILY HEALTH PERMISSION TO OPERATE USING THESE PRACTICES. A COPY OF THIS DOCUMENT CAN BE FOUND AT www.HOPEfamilyhealth.org/privacy

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SECTION 1 | HFH has a Commitment to Patient Privacy

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

HOPE Family Health (called HFH hereafter in this statement)  is careful to protect the privacy of our patients’ medical information. We respect your right to privacy and we comply with all federal and state laws that have been passed to insure your privacy. We handle your personal health information with the utmost care. We hope that this statement of our privacy practices answers any questions or concerns that you might have about the privacy of your personal health information. Please ask any member of our team to speak to HOPE’s Privacy Officer if there is anything you do not understand or wish to know more about.

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SECTION 2 | HFH is Mandated by Law to Protect Patient Privacy

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

HFH is required, as are all healthcare providers, by federal and state law to maintain the privacy of protected health information. We are also required by law to give you this statement and to operate by the practices as declared in this statement. These laws require us to give you this notice in advance of your first service whenever possible. Laws and regulations also allow us to collect information via phone or other means ahead of time to expedite (speed up) our service to you and allow us to treat you immediately in an emergency as long as we make a good faith effort to present you with the statement as soon as possible. ,. These laws go one step further and require that you as our patient sign this statement, acknowledging you have read and understand what it says. We are also required by law to prominently post this notice and any  future revisions in all of our places of service. If you do not see this notice posted, please ask any staff person to point it out to you. We can also give you a new copy at any time you may need.

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SECTION 3 | Statement Effective Date, Revisions, and Previous Versions

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

This edition of this notice is effective as of May 1, 2015, however an earlier version was originally effective on January 1, 2005. We may in the future find that it is necessary to change our practices, and/or update our privacy procedures, and reserve the right to do so without notice. Any change to our practices will be highlighted and dated on the posted statement of our practices at all of our service locations by the time any changes go into effect and we will begin distributing revised statements by the date that any changes take effect. You can always find the date when new practices went into effect at the top of any copy of this statement and our practices. We encourage you to check our posted practices each time you visit, or whenever you may have a question about your privacy as a patient. If we do find it necessary to change our practices over time we will not segregate (set apart or separate) our records according to the notice in effect at the time the entries into the records were created. We specifically reserve the right to not segregate our records in this notice. You are entitled to a copy of our privacy practices and any revisions at any time so please ask any staff person or ask to speak to the Privacy Officer if you ever have any questions or needs related to your privacy.

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SECTION 4 | The Patient Acknowledges Awareness and Understanding of this Statement

APPLICABLE FORM: HI002a1

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

The law further requires that we must make a good faith effort to obtain your written acknowledgment of receipt of this notice. That is why we are asking you (or your personal representative, for example, a parent of a child) to sign Form HI002a6 “Acknowledgement of Health Center Privacy Policy, Privacy Practices, and Privacy Procedures” saying that we have given you this notice. If you refuse or otherwise do not sign this acknowledgement, the staff person who presented it to you will sign a statement saying that they gave it to you for our records. The fact that you do not sign, does not change our practices, procedures, or our commitment to maintaining the privacy of your protected health information. If you have  questions at any time about this statement or anything in it, please ask  a member of the HOPE staff . If they do not answer your questions or address your concerns to your satisfaction please call the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org

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SECTION 5 | Storage, Security, Access and Dissemination of your Health Records

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

Your health records are maintained by HFH in a secure location, using technology that has been both designed for maximum security and tested for reliability. Any and all contractors (Business Associates, as defined by HIPAA law) that HFH partners with to assist in the storage and/or security of your health records, has entered into a Business Associates Agreement with HFH. This agreement holds the contractor/business associate accountable for maintaining specific procedures and standards when handling your protected information. This agreement also exists to hold third parties who interact with your health information to the highest standards of ethical behavior and procedural compliance. Your health records are made available only to those who need access to them, and then only to the minimum necessary extent to accomplish their job to help in your treatment, pursuit of payment or success of our healthcare operations. If maintained or shared electronically, reasonable and appropriate security measures will be in place to protect the privacy of your information. All staff are regularly trained in the methods of protection of your privacy and all staff have agreed in writing to abide by the practices and procedures as set forth in this notice.

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SECTION 6 | When HFH is Allowed by Law to Disclose Your Health Information

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

Per HIPAA law, we are allowed to use your personal health information for the purposes of treatment, payment and healthcare operations. , As a healthcare team,  in order to provide you the best treatment possible, we do  share your information among our professional staff and others directly involved in providing you with healthcare. . However, HOPE only allows staff members access to the specific information necessary for them to accomplish their purpose.  For example, billing staff can only access information needed to carry out the billing process, and medical staff can only access information needed to provide you with healthcare.

 

6.1   | Disclosures for Treatment

6.1a | Treatment in an Integrated Care Health Center

APPLICABLE TO MEDICAL HEALTH RECORDS, VISITS & TREATMENTS

HFH practices integrated healthcare. This means that if you are a medical patient, your Primary Care Medical Provider may think it is in the best interest of your overall health to share your information with one of our behavioral health staff.  Behavioral health staff may include Psychiatric Nurse Practitioners, therapists, or Behavioral Health Consultants  BHCs are behavioral health providers who are specially trained to function as part of the primary care team and to provide behavioral care and consultation within that setting. The single intention and only goal of your Primary Care Medical Provider sharing your health information with a BHC or other behavioral provider is to aid in the process of managing your overall healthcare while treating you . Your overall wellbeing as the patient (physically, mentally, behaviorally, emotionally and spiritually) is the most important part of our mission, and is at the center of every practice and procedure at HFH.

APPLICABLE TO BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

HFH practices integrated healthcare. This means that if you are a behavioral patient, your Behavioral Health Provider may think it is in the best interest of your overall health to share your information with one of our medical providers or with our Behavioral Health Consultant (BHC). BHCs and other Primary Care Medical Providers are intimately acquainted with other tools and other healthcare providers in the health center that may be able to further help you achieve overall maximum quality of health. The single intention and only goal of your Behavioral Health Provider sharing your health information with a BHC or Primary Care Medical Provider, is to aid in the process of managing your overall healthcare while treating you as the patient. Your overall wellbeing as the patient (physically, mentally, behaviorally, emotionally and spiritually) is the most important part of our mission, and is at the center of every practice and procedure at HFH.

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

In either of the two cases above, there will be some sharing of your information among our professional staff to maximize the benefits of your treatment possibilities and overall health while a patient at HFH. Also, nurses and other clinical staff will have access to your records to the extent that it is necessary to assist the clinician in your care. Additionally, because many of our patients choose to visit more than one of our locations your record will be used by staff at all locations that you visit for the purpose of your treatment. By signing the acknowledgement of this statement, you as the patient acknowledges that you are aware that your care may be internally shared/disclosed (when/if deemed necessary, and only when/if deemed necessary) amongst medical and behavioral providers in addition to other staff at HFH. If at any time you wish to revoke the privilege of any HFH provider or staff member from accessing, viewing, sharing, or disclosing your protected health information for any reason, you may do so by listing that individual in addition to your signature on the acknowledgement of this statement, or later by writing or by contacting the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org

 

6.1b | Other Disclosures of Medical Patient’s Medical Health Records Outside of HFH

APPLICABLE FORM: HI002a1

APPLICABLE TO MEDICAL HEALTH RECORDS, VISITS & TREATMENTS

Another illustration is that if your Primary Care Medical Provider finds it necessary to refer you to a Specialty Provider (a cardiologist, for example), the part of your record that is pertinent to the treatment of your condition will be forwarded to the Specialty Provider in advance of your visit with that provider. After that visit, the Specialty Provider’s records on your visit(s) to them will, in turn, be sent back to HFH to help HFH coordinate treatment. Sometimes a Specialty Provider must have access to your record in order to decide whether to accept the referral or not.   In that case, HOPE will send the specialty provider your records in advance to assist him or her in making this decision. When applicable and possible, HFH will require you to complete form (HI002a1) Authorization for the Release of Medical Health Information” prior to disclosing your health information to another health care provider outside of HFH. However, HIPAA law allows HFH to determine when and/or if prior authorization is required before making a disclosure of this nature, and does not require HFH to obtain any prior authorization from the patient if the disclosure is being made  to facilitate the medical treatment of the patient.

 

6.1c | Other Disclosures of Behavioral Health Patient’s Behavioral Health Records Outside of HFH

APPLICABLE FORM: HI002a2a

APPLICABLE TO BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

If you are a Behavioral Health patient who sees one of our Behavioral Health Providers for assessment and ongoing treatment, your rights are different under state law in Tennessee. While your behavioral health information CAN be shared INTERNALLY as necessary for your treatment and care without additional action on your part , any release of this  record to an outside entity other than your insurance company or other payor requires that we get you to sign an ADDITIONAL authorization allowing its release.  This additional release is called the “Release of Behavioral Health Information” and is different than the release you may have already signed for medical information.  Certain exclusions to this rule apply: for example, under certain circumstances we may be required to send your behavioral health records to a governmental agency for purposes including, but not limited to, legal proceedings, law enforcement reasons, public health reasons, or a Duty to Warn.  .

As an example of how Tennessee law governs the release of behavioral health information differently than the release of medical information,  if you move and want to go to another clinician, provider or facility outside our system, even if you have already signed a medical release requesting your medical records be forwarded to your new provider, we will ask you to sign a separate release, the  “Authorization for the Release of Behavioral Health Information(HI002a2a) before we send him or her your  behavioral health records.. . Or if your behavioral health provider at HFH refers you to another behavioral health provider at another hospital or facility, you will be requested  to add that clinician or facility to your “Release of Behavioral Health Information” in order to allow us to send them your behavioral records.

6.1d | Disclosures of Psychotherapy and/or Counseling Notes of Behavioral Health Patients

APPLICABLE FORM: HI002a2b

APPLICABLE TO BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

We must receive your authorization for any use or disclosure of psychotherapy and/or counseling notes, except in the following circumstances HFH is legally permitted to use/disclose your psychotherapy and/or counseling notes without your authorization:

  • For use by the originator of the psychotherapy notes for treatment or health oversight activities
  • For use or disclosure by HFH for its own training programs in which students, trainees, or providers in behavioral health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling
  • For use or disclosure by HFH to defend itself in a legal action or other proceeding brought by you (the patient)
  • To the extent required to investigate or determine HFH’s compliance with the HIPAA regulations
  • To the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law
  • For health oversight activities with respect to the oversight of the originator of the psychotherapy notes
  • For disclosure to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law
  • If disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to HFH, it is our intent to meet the requirements of the more stringent/applicable law.

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your psychotherapy and/or counseling notes only with a written authorization from you through form (HI002a2b)Authorization for the Release of Psychotherapy & Counseling Notes”. Once you give us this authorization to release your psychotherapy and/or counseling notes, we cannot guarantee that the person to whom the information is provided will not disclose the information further. You may take back or “revoke” your written authorization at any time in writing, except if we have already acted based on your authorization.

6.2   | Disclosures for Payment

6.2a | Disclosures for Collecting Payment

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

By law, we are allowed to use your information for the purpose of payment. This means that office and billing staff may use the minimum necessary amount of your information to collect payment from any insurer, government program or any other responsible payor including yourself.

 

6.2b | Disclosure for Insurance Purposes

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

When a patient chooses to use health insurance to pay for medical or behavioral health treatment at HFH, there are times when an insurance company or other payor will require us to send them a health record of the treatment for which payment is being requested, for their review and verification of benefits and coverage before they will pay a claim for services rendered by HFH. When such a request occurs, we review your record and send them only the minimum necessary amount of information that in our opinion satisfies their needs. HFH is obligated to disclose health information for this purpose.

 

6.2c | Disclosures Because of Contractual Obligations

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

Most health insurance plans have a contractual right (that both you and HFH have agreed to) to review your entire record on demand. If they make such a demand, we must comply. If you wish further information about this process, please contact the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org

 

6.3 | Disclosures for Healthcare Operations

6.3a | Disclosures for Internal Control and Administrative Purposes

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

We are allowed by law to use your information internally in the course of our healthcare operations. This means, for instance, that we can use your information to help us schedule, order supplies, review for Quality Assurance/Control or Risk Management or Corporate Compliance or any other way that we see fit to help us carry out, measure and improve the quality of care that we provide.

 

6.3b | Disclosures During Electronic Transmission

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

At times it is necessary to mail, fax or electronically transmit your personal health information for the purposes of treatment, payment or healthcare operations. For instance, you are being treated at another facility in an emergency and we must provide your medical record to the treating facility to aid in your treatment. In such a case and other cases, we may fax your  record to the treating providerin whole or in part. If we do so, we will make the effort to ensure that the fax is going where it is intended and being used for its intended purpose.

 

6.3c | Disclosures During other Types of Transfers

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

Similarly, at times it is necessary to transfer your information between our locations, billing contractors, or to an insurance company, governmental agency or other payor and we will use reasonable and appropriate security measures whether they are being transferred physically or electronically. If your record is maintained in electronic form, reasonable and appropriate measures will be taken to protect your personal information, access being allowed only to the minimum necessary extent that each staff member needs in order  to make their best contribution to your care. Precautions will be taken to prevent unauthorized access both within our health center(s) and from outside our health center(s). If you have questions about these reasonable and appropriate measures, please contact the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org

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SECTION 7 | Patient Revocation & Accessing other Disclosures

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

We will only release your records under the above circumstances. Any other uses and disclosures will be made only with your authorization.

 

7.1 | Revoking Authorization to Disclose

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

If you give us an authorization and later change your mind, you can revoke (cancel) that authorization.

Joey – do we need to explain how they should do that, i.e, in writing, or on a specific form?

7.2 | Active Disclosure Period

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

If you sign and then later cancel an authorization we will between the time of the authorization and the revocation (cancellation) be allowed to release your record as stated in the authorization that you signed.

 

7.3 | Other Disclosures Required by Law (ex: Judicial or Administrative Proceedings)

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

If we are at some point required by law to release your records to a government agency, such as law enforcement, the Department of Child and Family Services or to public health   authorities for example, or for any other reason, we are required to keep an accounting of all releases not covered under this statement of practices or by a separate authorization. You have the right to view a list of these releases. For a copy or for more information about this process please contact the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org.

 

7.4a | Disclosures of Abuse, Neglect, or Domestic Violence

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

We may disclose information about you to the appropriate authorities if we believe that you have been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

 

7.4b | Data Breach Notification Purposes

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information. We may send notice directly to you and/or the Department of Health.

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SECTION 8 | Request for Disclosure Restrictions

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

You can request restrictions in the handling of your information contrary to the practices described in this notice. Any request of this nature must be made in writing to the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org. Be aware that as we are already committed to keeping your information as private as possible, that any further restriction may interfere with your treatment, our right to pursue payment from a plan or insurer and may hinder our healthcare operations.

 

8.1 | As it Pertains to Collecting Payment for Services Rendered

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

If a restriction placed by the patient interferes with HFH’s ability to access or disclose your information while attempting to collect payment for services that have been rendered by HFH from the party responsible, such as an insurance company or other third party payor, such  restriction may cause responsibility for payment to fall exclusively to you.

 

8.2 | Right of HFH to Refuse Request for Restriction

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

In certain circumstances we are not required to or may not be permitted by law to honor your request for a restriction. If we feel that for whatever reason we can’t do as you ask, we will explain our reasons to the best of our abilities.

 

8.3 | Patient Request for Privacy through Alternative Communication

APPLICABLE FORM: HI002a5

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

You have the right to request that we communicate with you in a confidential manner or at a specific location. For example, you may ask that we only contact you via mail at a post office box or that we only call your cell phone instead of a home phone. You must submit your request in writing through form (HI002a5)Patient Request for Privacy through Alternative Communication”. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.

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SECTION 9 | Patient’s Right to Access Their Health Record 

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

You have the right to review or receive a copy of your health record at any time. Tennessee state law requires that HFH maintain a copy of your health record for no less than 10 years from the last treatment date or last professional contact with the patient, or 1 year after a minor patient reaches the age of maturity (i.e., until patients 19th birthday), whichever is longer. Because HFH submits a Cost Report to Medicare, federal law requires that health records for services paid for by Medicare must be kept for no less than 10 years. State and federal law provides different regulations, guidelines and requirements for certain types of services rendered within the health record such as specific diagnostic testing, reports, imaging, labs, etc. As to create a standard for health record retention that insures compliance with all federal and state laws and regulations, it is the practice of HFH to maintain a patient’s complete and full health record (including all reports and diagnostics) for  no fewer than 10 years after the last treatment date OR the date of which the patient was deceased  (whichever comes first).

 

9.1 | Requesting a Patient Copy of a Medical Heath Record

APPLICABLE FORM: HI002a1

APPLICABLE TO MEDICAL HEALTH RECORDS, VISITS & TREATMENTS

HFH does not charge a patient a fee for a personal copy of his/her medical health record. We do have the right by law, however, to charge a patient for the cost we accrue of making copies and/or the printing of this information. You must make this request in writing by completing form (HI002a1)Authorization for the Release of Medical Health Information”. HFH needs adequate time to prepare the health record for its release which may include archive research, printing, copying, etc.. This authorization must be given in-person by either the patient or the patient’s legally authorized representative (with Power of Attorney). The release of the health record will be made only to the patient directly (in-person) or to his/her legally authorized representative (with Power of Attorney).

 

9.2 | Requesting a Patient Copy of a Behavioral Heath Record

APPLICABLE FORM: HI002a2

APPLICABLE TO BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

HFH does not charge a patient a fee for a personal copy of his/her behavioral health record. We do have the right by law, however, to charge a patient for the cost we accrue of making copies and/or the printing of this information. You must make this request in writing by completing form (HI002a2)Authorization for the Release of Behavioral Health Information”. HFH needs adequate time to prepare the health record for its release which may include archive research, printing, copying, etc. (5 business days). This authorization must be given in-person by either the patient or the patient’s legally authorized representative (with Power of Attorney). The release of the health record will be made only to the patient directly (in-person) or to his/her legally authorized representative (with Power of Attorney). Behavioral health records have a different level of complexity than that of medical health records. Because of that, it is the practice of HFH that a Behavioral Health Provider be available to review and explain your record to you at the time of its release. As such, behavioral health record disclosures directly to a patient will require you to visit one of our locations by appointment. There will be no added charge for this service.

 

9.3 | Requesting for an Amendment to a Patient Health Record

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

If you do not agree with something in your health record or find an inaccuracy, you have the right to make a request to amend it. Any request of this nature must be made in writing to the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org.

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SECTION 10 | Business Associates

APPLICABLE FORM: HI002a3

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

As required by HIPAA law through the HITECH Act of 2009, HFH will require its Business Associates (a third party individual or company that performs services for HFH in the areas of treatment, payment or healthcare operations) to sign statements of acknowledgement to, and agreement with, our Privacy Practices “Business Associates Agreement” (HI002a3). As a practice, HFH includes these agreements in contracts with our Business Associates. Our Business Associates, whether information is shared with them incidentally or in the course of treatment, payment or healthcare operations, agree to protect your privacy in the same ways that we do by signing these specific agreements.

 

10.1 | Health Information Disclosed for Marketing or Research

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

HFH will never use or share your personally identifiable protected health information with anyone for marketing or research purposes without clearly explaining to you how your information will be used and having you sign an authorization for this use ahead of time. Any information that we share without a specific authorization outside the reasons stated in this Statement will be de-identified (meaning that we will remove all personal information).

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SECTION 11 | Reporting Privacy Violations or Misuse

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

If any patient, employee or business associate feels that a violation of patient privacy has occurred, or that any misuse of protected health information has taken place, or that any part of this Statement of Practices has not, or is not being followed in its entirety, please contact the health center’s Privacy Officer, Joey Forman, CIO, CCO at (615) 644-2000 and use extension 473. Or you can email the privacy officer at joeyforman@hopefamilyhealth.org.

 

11.1 | Filing a Complaint with the Federal Government through HHS

EQUALLY APPLICABLE TO BOTH MEDICAL AND BEHAVIORAL HEALTH RECORDS, VISITS & TREATMENTS

It is our desire to immediately address your concerns. However, if your concerns are not addressed to your satisfaction you may complain to the Secretary of Health and Human Services:

Email: OCRComplaint@hhs.gov
Phone: 1-800-368-1019 or 1-800-537-7697
Mail:    Office for Civil Rights U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

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SECTION 12 | Equal Access to Policy, Practices & Procedures

This notice is available in both English and Spanish and can be made available to those who  speak other languages or who may be blind or unable to read, if the patient gives HFH sufficient notice to prepare a translation or another means by which to make this information available.

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SECTION 13 | Laws, Statutes and Regulations used in the Development of Practices & Procedures

The following laws, statutes and/or regulations were reviewed, taken into account, or otherwise used in the development of the Privacy Practices & Procedures of HFH:

 

13.1 | State of Tennessee Statutes

  • Tenn. Comp. R. & Regs. 0880-2-.15 (2008)
  • Tenn. Code Ann. (~legal swiggly) 68-11-305(a)(1) (2008)
  • Tenn. Code Ann. (~legal swiggly) 68-11-305(a)(2) (2008)
  • Tenn. Title 33, Tennessee Code Annotated

 

13.2 | Federal Statutes

  • The Patient Safety and Quality Improvement Act of 2005 (PSQIA)
  • Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  • HIPAA Privacy Rule – Standards for Privacy of Individually Identifiable Health Information
  • HIPAA Security Rule – Security Standards for the Protection of Electronic Protected Health Information
  • Pub. L. 104-191.
  • 68 FR 8334.
  • 45 C.F.R. § 160.103.
  • 45 C.F.R. § 164.306(a).
  • 45 C.F.R. § 164.304.
  • 45 C.F.R. § 164.306(b)(2).
  • 45 C.F.R. § 164.306(e).
  • 45 C.F.R. § 164.306(b)(iv).
  • 45 C.F.R. § 164.308(a)(1)(ii)(B).
  • 45 C.F.R. § 164.306(d)(3)(ii)(B)(1); 45 C.F.R. § 164.316(b)(1).
  • 45 C.F.R. § 164.306(e).
  • 45 C.F.R. § 164.308(a)(1)(ii)(D).
  • 45 C.F.R. § 164.306(e); 45 C.F.R. § 164.308(a)(8).
  • 45 C.F.R. § 164.306(b)(2)(iv); 45 C.F.R. § 164.306(e).
  • 45 C.F.R. § 164.308(a)(2).
  • 45 C.F.R. § 164.308(a)(4)(i).
  • 45 C.F.R. § 164.308(a)(3) & (4).
  • 45 C.F.R. § 164.308(a)(5)(i).
  • 45 C.F.R. § 164..308(a)(1)(ii)(C).
  • 45 C.F.R. § 164.308(a)(8).
  • 45 C.F.R. § 164.310(a).
  • 45 C.F.R. §§ 164.310(b) & (c).
  • 45 C.F.R. § 164.310(d).
  • 45 C.F.R. § 164.312(a).
  • 45 C.F.R. § 164.312(b).
  • 45 C.F.R. § 164.312(c).
  • 45 C.F.R. § 164.312(e).
  • 45 C.F.R. § 164.306(d).
  • 45 C.F.R. § 164.314(a)(1).
  • 45 C.F.R. § 164.316.
  • 45 C.F.R. § 164.316(b)(2)(iii).
  • 45 C.F.R. § 160.203.
  • 45 C.F.R. § 160.202.

 

Pharmacy-Assistance 

Our on-site pharmacy-assistance services are available for our patients who need help in obtaining affordable medications. Through a variety of resources we try to offer patients samples, pharmacy discount programs, and a variety of other tools to help them obtain the medication they need when they need it and in a way in which they can afford.

Laboratory Services
Our laboratory services are available for patients while obtaining health-care at HOPE Family Health and include on-site diagnostic laboratory testing and screening through a partnership with LabCorp (Laboratory Corporation of America). This gives our providers a stronger advantage in quickly and efficiently meeting the healthcare needs of our patients.

Se Habla Espańol

In addition to Spanish translation services, we provide translation interpretation services for many patients who may not speak English as their primary language. For more information…

Call | 615-644-2000.
E-mail | info@hopefamilyhealth.org