Notice of Privacy Practices
Notice of Privacy Practices (Microsoft
Word*) (Adobe
PDF*)(free viewer)
1. Who we are
This notice describes the Privacy Practices of the Dorothea
Dix Psychiatric Center system, which includes inpatient
and outpatient services, the Dental Clinic, and all individuals
who work in or for these programs.
2. Our Privacy Obligations
We are required by law to keep your health
information private in many situations (protected health information-
PHI), to tell you about these rules and to follow the rules.
3. Disclosing and Using Your Information With your consent
When you
begin receiving care from us, we will ask you (or your legally authorized
representative) to sign a consent form that will permit us to provide
care for you. We will also ask you to sign a reimbursement form
giving us permission to get preauthorization for your care and/or
to bill for the care provided. This may also include providing them
with copies of your medical and personal information. You may revoke
your permission that allows us to use your information after the
date of the revocation, but you must do this in writing.
Please note that a revocation may affect our ability to provide you
care.
4. Using Your Information (PHI) with your authorization
As described
above, we will use your signature on the consent form to release
information for treatment, payment, or other health care operations.
We may use PHI for other reasons only when we:
- have a specific authorization signed by you or your legally
authorized representative, or if
- there is an exception as described below in section 5.
You have the right to withdraw (revoke) your permission at
any time. You can do this by sending the Privacy Officer at
Dorothea Dix Psychiatric Center a letter.
5. Exceptions
There are exceptions to use or disclose your information
because we may be unable to obtain your authorization or it
may be mandatory for us to report. We will release only what
information is necessary. Examples of when we might use your
PHI without authorization includes:
- emergency treatment
- medical care required by law
- suspected abuse and neglect of children and incapacitated
adults
- to the Public Health Authorities to help stop the
spread of diseases
- if we believe you represent a threat to the safety of
someone or yourself
- required to provide information about you to organizations
that oversee the care we provide , such as The Joint Commission,
Department of Health and Human
Services, CMS, etc.
- required to provide information about you in response
to an investigative subpoena or a court order (including
law enforcement officials concerning certain issues)
- required to report to the coroner or medical examiner
and notify the organ bank upon death
- required to provide patient information to Workers’ Compensation
(only pertaining to the injury relating to the
compensation)
- required to report information about products
you may have used to the Food and
Drug Administration
- may permit access to information about you to students,
contracted agencies for the Department of Health
and Human Services and others who are conducting research
Activities, which have been approved by Administration
6. Your Rights
- If you want more information about your Privacy Rights or
our Privacy Practices, or are concerned that we have not followed
our rules, you may contact our Privacy Officer or Patient Advocate or
the Disabilities Rights Center. You may also file a written complaint
with the Director of the Office for Civil Rights. Upon request, we will
provide you with the address. We will not retaliate against you if you
file a complaint of any kind.
- You may request access to your PHI. All reviews are supervised.
You may get a copy of your record for a reasonable charge.
We will provide a copy of your discharge summary free of charge (MR
Policy #2.2You may request access to your PHI.)
- You may request that we amend your records. We will comply with
your written request or respond in writing why we do not
feel the amendment is appropriate. (See MR Policy # 3.2) You have the
right in either case to add your own addendum to the records. A copy
of this addendum will be released whenever we release copies of your
record.
- We will accommodate to the extent that we can any request in
writing that asks us to communicate with you by a different
means of communication or at a different address.
- *You may request a list of recipients of your PHI released for
purposes other than treatment, payment, and operations. You are entitled
to one free “accounting” per 12-month period.
There will be a reasonable cost for additional requests.
(See MR Policy # 2.4)
- You must receive a copy of this notice.
- You may ask us in writing to restrict the use and disclosure
of PHI. We cannot promise to agree to every request you
make; but, if we agree, we must abide by the agreement.
- If you want to tell us how we can contact you after you leave
the hospital, please do this in writing (i.e., you might
prefer that we call you at work).
7. Effective Date
These requirements are effective on April 14, 2003. We reserve
the right to change the terms of this notice at any time.
If we do so, we will place the updated version in the waiting
areas and on the Dorothea Dix Psychiatric Center web site.
You may also get a copy of the updated notice in the Medical
Record Department.
Maine Law controls if it is more protective of your privacy
than federal law.
Contact Information:
Privacy Officer
Dorothea Dix Psychiatric Center
626 State Street
PO Box 926
Bangor, ME 04402-0926
Phone: 207-941-4031
Cheryl.Cropley@maine.gov
|
Patient Advocate
Dorothea Dix Psychiatric Center
626 State Street
PO Box 926
Bangor, ME 04402-0926
Phone: 207-941-4180
|
Disabilities Rights Center
24 Stone Street
PO Box 2007
Augusta, ME 04338
Phone: 207-626-2774 or 1-800-452-1948 |
Form #: 871 – Original “acknowledgement form” in
the patient’s record
Effective: 4/14/03; REVISED: 6/19/03; 10/05, 05-06; 11/07
