EFFECTIVE DATE: 04/14/2003 

THIS DOCUMENT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. THIS IS A REQUIREMENT IMPOSED BY THE FEDERAL GOVERNMENT. PLEASE REVIEW IT CAREFULLY. This notice will tell you how we may use and disclose protected health information about you. Protected Health Information (PHI) means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you. You will be asked to provide a signed acknowledge of receipt of this notice.

How We May Use and Disclose Protected Health Information (PHI) 

We may use or disclose your PHI as necessary to carry out treatment, payment or other health care operations. Some instances where your PHI may be disclosed are listed below:


PHI may be used to provide and manage your health care. We may share PHI with other health care providers as part of a referral to that provider.


We may send a bill to a third-party payer, such as an insurance company for payment. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.


We may use and disclose your PHI for our own health care operations. For example, staff may look at your PHI when reviewing the quality of services that you are receiving. Members of the risk or quality assessment/improvement team may use information in your health record to assess the quality and effectiveness of the healthcare and services we provide. We may use your PHI to determine your eligibility for additional services.


We may contact you by telephone or by mail at either your home or workplace, unless you tell us otherwise in writing. At either location, we may leave messages for you on the answering machine or voicemail. You have the right to request that we send you confidential communications by alternative means or at an alternative location. To request confidential communication, you must do so in writing to the Privacy Office in care of the Powell County Health Department at 376 North Main Street, Stanton, KY 40380. Your request must state how or where you can be contacted. We will accommodate your request. However, we may also require and alternate address, phone number or other method to contact you.


Unless you object, we may contact you as a reminder of your scheduled appointment either by telephone, mail or an auto dialer (automated reminder).


Unless you object, we may disclose to a member of your family, a close friend or any other person you designate, your PHI that directly related to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based upon our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your location, general condition or death.


We may use or disclose PHI about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.


We may use or disclose your PHI if law or regulation require the use/disclosure.


As required by law, we may disclose your PHI to state and federal public health, legal authorities charged with preventing or controlling disease, injury or disability. We may share your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may be at risk of getting or spreading the disease or condition. Information will be released to avert a serious threat to health or safety. Any disclosure, however, would only be to someone authorized to receive that information pursuant to law.


We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.


We may disclose your relevant PHI to the Cabinet for Families and Children that is authorized by law to receive reports of abuse, neglect and exploitation. In addition, we may disclose your relevant PHI if we believe that you have been a victim of abuse, neglect, exploitation or domestic violence to the governmental agency authorized to receive such information.


We may share your PHI with health oversight agencies such as audits, investigations, inspections, licensure or disciplinary actions. Such activities are necessary for appropriate oversight of the healthcare system, government benefit programs, and entities subject to various government regulations.


We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information (See Cabinet for Health Serviced Administrative Order, CHS 01-08, August 28, 2001) (Institutional Review Board for the Protection of Human Subjects).


We may disclose PHI to a coroner or medical examiner for identification purpose, determine cause of death or for the coroner or medical examiner to perform other duties authorized be law. We may also disclose relevant PHI to a funeral director, as authorized by law in order to permit the funeral director to carry out their duties.
We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes.


We may disclose health records for law enforcement purposes as required by law or in response to a valid subpoena, discovery request or other lawful process. These law enforcement purposes include (1) legal processes; (2) limited information requests for identification and location purposes; (3) pertaining to victims of a crime; (4) suspicion that death has occurred as a result of criminal conduct; (5) in the event that a crime occurs on the premises of the Department, including its facilities; and (6) medical emergency and it is likely that a crime has occurred. Also, we may disclose information to government agencies.


We may disclose your PHI to a correctional institution or law enforcement official having custody of you. The disclosure will be made necessary if the following condition apply (1) to provide health care to you; (2) for the health and safety of others; and (3) the safety security and good order of the correctional facility.


We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation and similar laws that provide benefits for work related injuries or illness without regard to fault.


Uses and disclosures of you PHI beyond treatment, payment and operations, will be made only with your written authorization, unless otherwise permitted or required by law as described above. Information that is not Personally Identifiable.


You have the following rights concerning the PHI that we maintain about you. Although the medical record is the physical property of the health department, the information belongs to you.


You have the right to request a restriction of certain uses and sharing of your PHI. This means you may ask us not to use or share any part of you PHI for purposes of treatment, payment or healthcare operations. You may also ask that this information not be disclosed to family members or friends who may be involved in your care. You may send your request for a restriction in writing to: Privacy Officer in care of the Powell County Health Department, 376 North Main Street, Stanton, KY 40380. Your request should include (1) what information you want to limit; (2) whether you want to limit use or disclosure or both; (3) to whom you want the limits to apply (for example: disclosure to your spouse). We are not required to honor your requested restriction.


You have the right to inspect and receive a copy of your medical record. Request to inspect and/or receive a copy of your medical records should be sent to the Privacy Officer in care of the Powell County Health Department, 376 North Main Street, Stanton, KY 40380. Certain information contained in your record may be restricted by law from inspection or copying.


You have the right to request your medical information be changed. To request a change in your medical information, submit your request in writing to the Privacy Officer in care of the Powell County Health Department, 376 North Main Street, Stanton, KY 40380. We have the right to deny changes in medical records.


You have the right to obtain a listing of certain health information we were authorized to share for purposes other than treatment, payment or health care operation after April 14, 2003. Request for a list of disclosures must be submitted in writing to the Privacy Officer in care of the Powell County Health Department, 376 North Main Street, Stanton, KY 40380.



We are required to maintain the privacy of your health information. We are required to provide you a copy of this notice of privacy practices.


We have the right to change this Notice of Privacy Practices. If we make a change to this notice we are required to provide you with a copy of the new Notice of Privacy Practices. You may obtain a copy of our current Notice of Privacy Practices at any time by requesting a copy in writing to the Privacy Officer in care of the Powell County Health Department, 376 Main Street, Stanton, KY 40380.


are required to notify you in writing if we are unable to agree to a restriction or amendment you have requested. We are required to accommodate reasonable requests you may have to communicate health information by alternative means or alternative locations.


If you have any questions or want more information concerning this Notice of Privacy Practices, please contact the Privacy Officer in care of the Powell County Health Department, 376 North Main Street, Stanton, KY 40380 or call (606) 663-4360.

To file a complaint, you may contact the Privacy Officer, 376 North Main Street, Stanton, KY 40380 or The Secretary of Health and Human Services, Room 615F, 200 Independence Avenue S.W.; Washington, D.C. 20201 or call 1-877-696-6775 or the United States Office of Civil Rights by calling 1-866-627-7748 or 1-866-788-4989 TTY.

The Powell County Health Department cannot take away your health care benefits or retaliate in any way if you choose to file a Privacy Complaint or exercise any of your Privacy Rights.

The effective date of this notice is April 14, 2003.

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