Joint Notice of Privacy Practices

Virginia Mason Medical Center including Virginia Mason Hospital, Clinics, Ambulatory Surgery Centers, Bailey-Boushay House and Benaroya Research Institute at Virginia Mason

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Our mission at Virginia Mason is to improve the health and well-being of the patients we serve. This commitment extends to caring about our patients’ privacy.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We keep a record of the health care services we provide you. You may ask to see and to obtain a copy of that health information. You may also ask us to correct that health information. We will not disclose your health information to others unless you direct us to do so or unless the law authorizes or compels us to do so.

Who will Follow This Notice

This joint notice of privacy practices applies to the above Virginia Mason facilities, its medical staff, and other independent health care providers that provide services at Virginia Mason facilities and have agreed to follow this notice. The independent health care providers likely will have separate notices of privacy practices for care delivered at non-Virginia Mason facilities.

Your Health Information Rights

You have certain rights over the use and disclosure of your health information, including the rights listed below. You may contact our Release of Information Department at 206-223-6975 or visit our website at www.virginiamason.org for more information about how to exercise these rights. In most cases, we require you to submit a written form to exercise your rights.

Inspect and Copy

You have the right to inspect and obtain a copy of your health information in most cases. If we maintain your health information electronically, you may also request that we provide your information in an electronic form and format. If the requested electronic form and format is not readily producible, we may provide the information in another readable electronic form and format. If you request a copy, we may charge a fee for the costs of copying, mailing or other supplies and the electronic media associated with your request.

Request Amendment

You have the right to request in writing an amendment to your health information if we created it and we agree that it is either wrong or incomplete. If we do not agree to make the amendment, you may add a statement of disagreement to your health information.

Accounting of Disclosures

You have the right to obtain an accounting of certain disclosures.

Request Restrictions

You have the right to ask us not to let your insurance company know about an item or service we provide if you pay in full before we send a bill. There are certain conditions that must be met for us to comply with your request. You also have the right to ask us in writing to restrict certain other uses and disclosures of your health information. We are not required to grant all of these requests, but we will honor any requests we do grant.

Revoke

You have the right to revoke any written authorization to use or disclose health information, except to the extent that we have already acted. Researchers may also keep information they have already collected.

Alternative Communications

You have the right to request in writingthat we contact you by alternative means or at alternative locations.

Obtain Notice of Privacy Practices

You have the right to obtain a paper copy of this notice by asking for it, even if you previously agreed to accept a notice by e-mail or over the Internet.

Receive Notification of a Breach

You have the right to receive notice from us if we discover a breach of your unsecured health information according to the requirements of federal and state law.

Our Responsibilities

We are required to protect the privacy of your information, provide this notice about our privacy practices, and follow the privacy practices that are described in this notice.

For More Information or to Make a Complaint

If you have questions or would like to make a complaint, you may call the Virginia Mason Privacy Office at 206-223-7505.

If you have a complaint, you may also contact the federal Office for Civil Rights, Region X, U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Notice Changes

We reserve the right to change our notice of privacy practices and to make any new notice effective for all health information that we maintain now or in the future. If our privacy practices change, we will post the new notice at each Virginia Mason facility and on our website at www.virginiamason.org.

Uses and Disclosures for Treatment, Payment and Health Care Operations

The following categories describe the ways that we may use and disclose your health information for treatment, payment and health care operations.

Treatment

We will use and disclose your health information for treatment. Treatment means providing and arranging for your health care and health-related services with other providers. It may also include coordinating your care with a third party, obtaining a consultation from another provider, or making a referral.

Some examples: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of your treatment. We will also provide other health care providers with copies of various health information or electronic access to your health information that could assist them in treating you.

Payment

As permitted by law, we will use and disclose your health information for payment activities. Payment activities generally include billing, collections, and obtaining prior approval from your insurance plan for the care that we provide. Public and private insurance plans may require us to disclose your health information for the purposes of audits, inspections, and investigation.

Some examples: We may send a bill to your insurance plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used so we can get paid for the treatment we provide. We may disclose certain information to consumer reporting bureaus for collection of payment.

Health care operations

We will use and disclose your health information for health care operations. Health care operations means a wide range of activities to run our business (or those of other health care organizations as allowed by law) and to ensure patients receive quality care.

Some examples: We may use or disclose your health information to review and improve the care you receive, to train our workforce and others, and to make processes more efficient.

Other Permitted or Required Uses and Disclosures

We may use and disclose your health information to make healthcare services better, protect patient safety and public health, make sure we follow government and accreditation standards, and when otherwise required or permitted by law. Such uses and disclosures include:

Organized Healthcare Arrangements

We may use and disclose your health information to individuals and organizations that participate in joint health care activities with us. These joint arrangements are referred to as “organized health care arrangements” under federal law. We have organized health care arrangements with our Hospital and its medical staff, Yakima Valley Memorial Hospital, its medical staff and Memorial Physicians; EvergreenHealth; Franciscan Health System; Seattle Children’s and the American Joint Replacement Registry. For more information, you may contact our Privacy Office.

Community Provider Access

We provide access to our electronic health information system to certain community providers. Providers with a “need to know” generally have full access to your electronic health information to improve care coordination and quality outcomes.

Some examples: we may provide access to referring community physicians and their staff, hospitals, and nursing facilities.

Health Information Exchanges

We participate in health information exchanges with local hospitals, physicians, insurance plans, and other healthcare organizations. These information exchanges allow healthcare organizations to send and receive your health information when there is a need for this information for treatment, payment, or in limited circumstance, healthcare operations.

Some examples: We disclose basic information regarding any emergency department visits you make to a health information exchange. The purpose of this exchange is to enable local emergency departments to coordinate patient care and reduce unnecessary services.

Patient Portal (MyVirginiaMason)

We provide you, or individuals authorized by you, with limited access to your electronic health information through MyVirginiaMason, a patient portal. Certain limitations apply to its use by minors and their parents/guardians.

Business Associates

We may also share your health information with other businesses that provide services to us such as consulting, legal services, transcription, accreditation, coding, billing, and collections. These “business associates” of ours are required to comply with federal privacy and security laws to safeguard your information.

To Contact You

We may contact you as a reminder that you have an appointment with us, provide test results, inform you about treatment options, ask you if you would like to participate in quality assessments or research, or advise you about health-related benefits and services.

Fundraising

We may use and release certain information to our foundation so that it may contact you to make donations that will support our charitable mission. This information would be limited such as your name, address, telephone number, dates and departments of service, age, gender, treating physician, outcome information and health insurance status. If we contact you, we will also provide you with a way to opt-out of receiving fundraising requests in the future.

Directory

Unless you notify us that you object, we may use your name, location in the facility, and general condition for directory purposes. This information may be provided to people who ask for you by name. We may also provide your religious affiliation to members of the clergy. In an emergency, we are permitted to use such information in your best interest as determined by our professional judgment.

Notification

Unless you notify us that you object, we may use or disclose information to notify (or assist in notifying) a family member, personal representative or another person responsible for your care, of your location in our facility and your general condition.

Communication with family and friends

Unless you notify us that you object, we may use our best judgment and disclose your health information to a family member, other relative, personal representative, close personal friend or other person you identify, that is relevant to the person’s involvement in your care or payment for your care.

Professional judgment

We are permitted to make disclosures if you are present or if you are otherwise available prior to a disclosure of health information and you either agree to it or we reasonably infer from the circumstances that you would not object. Even if you are not present, we may make a professional judgment that certain disclosures are in your best interests. For example, we may permit someone other than you to pick up your prescription.

Research

We may disclose information to researchers with your authorization, or without your authorization in some cases if the research has been approved by an Institutional Review Board (IRB). For example, a researcher may seek permission from an IRB to look at historical medical data in charts without obtaining an authorization from each person. In these cases, the IRB will determine if using your health information without your authorization is justified, and make sure that steps are taken to limit its use. Additionally, we may allow researchers to review your health information to assist them in developing research or we may contact you to ask if you would like to participate in a research study. In all other cases, we must obtain your authorization to use or disclose your health information for research.

Other Miscellaneous Uses and Disclosures

We also use and disclose your health information to enhance health care services, protect patient safety, safeguard public health, ensure that our facilities and staff comply with government and accreditation standards, and when otherwise authorized by law. For example, we disclose information:

  • To public health authorities with information on communicable diseases, vital records, health statistics, or acts of violence and at-risk behaviors;
  • To appropriate government agencies or law enforcement when we suspect abuse or neglect;
  • To the U.S. Food and Drug Administration (FDA) about FDA-regulated drugs and devices;
  • To a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • Your employer regarding medical surveillance of the workplace or evaluation of work-related illnesses or injuries;
  • To a school regarding your proof of immunization;
  • To a health oversight agency for activities authorized by law such as audits, investigations, inspections, and licensure;
  • To government programs providing public benefits such as Medicare and Medicaid if relevant to your eligibility and enrollment;
  • In response to a court or administrative order, subpoena, discovery request, or other lawful process;
  • To law enforcement when required or permitted by law; To coroners, medical examiners, and funeral directors;
  • To organ procurement organizations to coordinate organ donation activities;
  • To appropriate agencies or persons when we believe it necessary to avoid a serious threat to health or safety of a person or the public or to prevent serious harm;
  • To military command authorities or foreign military authority if you are a member of the armed services;
  • To federal officials for national security, intelligence, and protective services to the United States President and other officials;
  • To correctional institution or law enforcement official if you are an inmate or under custody; To workers’ compensation agencies and self-insured employers for work-related illnesses or injuries;
  • To cancer registries with information on identified cancer cases;
  • To trauma registries with information on the incidence, severity and causes of traumatic injuries;
  • To a public or private entity (such as FEMA or the Red Cross) authorized by its charter or law to assist in disaster relief efforts;
  • To a public oversight agency, public health authority or an attorney for whistleblowing activities regarding unlawful conduct or potentially endangerment of one or more patients, workers or the public;
  • When otherwise required or permitted by federal, state, or local law.

Use and Disclosure Requiring Your Authorization

Other than the uses and disclosures described above, we will not use or disclose your health information without your written authorization. Virginia Mason requires your written authorization for most uses and disclosures of psychotherapy notes, for marketing (other than a face-to-face communication between you and a Virginia Mason workforce member or a promotional gift of nominal value), or before selling your health information.

Special Health Information

Special state and federal protections apply to certain classes of health information. For example, additional protections may apply to mental health, alcohol and drug abuse, sexually transmitted disease and HIV information. When required by law, we will contact you to get written authorization to use or disclose that information.

Release of Information Departments

Bailey-Boushay House(206) 322-5300
Downtown and all Satellite Locations(206) 223-6975

Effective Date: March 23, 2016                                                    Joint Notice of Privacy Practices                                                         VMMC Form 901065 (03/16)