Effective Date: January 15, 2018
Who will follow this notice
This Notice describes the privacy practices of Covenant Health system hospitals, health care facilities, and health care entities, including Claiborne Medical Center, Cumberland Medical Center, Fort Loudoun Medical Center; Parkwest Medical Center; Fort Sanders Regional Medical Center; LeConte Medical Center; Methodist Medical Center of Oak Ridge; Roane Medical Center; and Morristown-Hamblen Healthcare System; as well as physician practices/clinics and sleep, breast, endoscopy, weight management, coumadin, diabetes, joint replacement, wound treatment, diagnostic, cardiac and pulmonary rehabilitation, DME, wellness, and surgery centers that are departments or divisions of, or are wholly owned by, such hospitals; Thompson Cancer Survival Center; Cumberland Physician Group; Fort Sanders West Diagnostic Center; Covenant Medical Group and associated physician practices; MMC Healthworks; Fort Sanders Perinatal Center; Knoxville Heart Group; East Tennessee Cardiovascular Surgery Group, Inc.; Covenant HomeCare; Thompson Oncology Group; Patricia Neal Rehabilitation Center; Covenant Therapy Centers; Claiborne EMS; and Fort Sanders West Outpatient Surgery Center (the “Covenant Health Entities”, or individually, a “Covenant Health Entity”), as well as any health care professional authorized to enter information into a healthcare record at a Covenant Health Entity; all departments and units of each Covenant Health Entity performing covered functions; any member of a volunteer group that a Covenant Health Entity allows to help patients while in the care of a Covenant Health Entity; business associates of the Covenant Health Entities; and all Covenant Health Entity employees, staff, and personnel.
Each Covenant Health Entity, their employees, staff and personnel, and the health care professionals providing services at the Entity participate in an “organized health care arrangement” that permits sharing of protected health information (“PHI”) to carry out treatment, payment, and health care operations related to the arrangement. Additionally, each Covenant Health Entity and the members of such Entity’s organized health care arrangement participate in a master organized health care arrangement that permits all of the Covenant Health Entities to share PHI for the same purposes under similar arrangements. Each of the participants in the organized health care arrangements remains solely responsible and liable for its/his/her own acts and omissions. These organized health care arrangements do not create a joint venture, partnership, agency, or employment relationship, and joint and several liability is not intended.
When this notice applies
This Notice applies to all of the records of your care generated by a Covenant Health Entity, whether made by Covenant Health Entity personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the use and disclosure of your PHI created in the doctor’s office or clinic.
The Covenant Health Entities are required by law to make sure that PHI is kept private, to provide this Notice of our legal duties and privacy practices with respect to PHI, to follow the terms of the Notice currently in effect, and to notify affected individuals following certain breaches of unsecured PHI.
How we may use and disclose PHI
The following categories describe different ways that the Covenant Health Entities use and disclose PHI. Although not every use or disclosure in a category will be listed, all of the ways we are permitted to use and disclose PHI will fall within one of the categories.
Treatment. We may use PHI to provide or arrange for medical treatment. We may disclose PHI to doctors, nurses, technicians, medical students, or other healthcare personnel or facilities involved in a patient’s care. For example, different departments of a Covenant Health Entity may share PHI to coordinate the different things a patient needs, such as prescriptions, lab work and x-rays. We may also use and disclose PHI to arrange for health care (e.g., referrals to specialists; transfers or referrals to other health care providers, including arranging for care once a patient is discharged from a hospital, etc.) We may also use and disclose PHI to send treatment-related communications concerning treatment alternatives or other health-related products or services.
Payment. We may use and disclose PHI to create bills and process payments. For example, we may provide a health insurer with information about a surgery a patient received so the insurer will pay for the surgery. We may also tell a health insurer about a treatment a patient will receive to obtain prior approval, or to determine whether the insurer will cover the treatment.
Health Care Operations.* We may use and disclose PHI for the operation of the Covenant Health Entities. These uses and disclosures are necessary to run the Covenant Health Entities and to ensure that all patients receive quality care. For example, we may use PHI for internal review of treatment and services and to evaluate staff performance. We may combine PHI about many of our patients to decide what additional services the Covenant Health Entities should offer, what services are not needed, and whether certain new treatments are effective. The Covenant Health Entities may share PHI with each other to conduct overall quality assessment and improvement activities, to review the competence or qualifications of health care professionals, and to conduct fraud and abuse detection programs. We may also disclose PHI to doctors, nurses, technicians, medical students, and other Covenant Health Entity personnel for review and learning purposes. We may also combine the PHI we have with PHI from other healthcare systems to compare how we are doing and see where we can make improvements in the care and services we offer. *Note. We may remove from PHI information that identifies individuals so it may be used without learning the identity of specific patients.
Patient Contacts. We may contact patients by telephone, email, or text message to advise them of upcoming appointments and needed follow-up services, treatment options or alternatives, health-related benefits or services of interest, survey participation, and for other lawful treatment and health care operations purposes using any of the telephone numbers and/or email addresses you provide (e.g., on patient intake forms or registration materials). We may use any method of contact to the telephone numbers provided, including automatic dialing devices. Please keep in mind text messaging and email are not secure forms of communication and information contained in texts and emails sent to the telephone numbers or email addresses you provide could be accessed or used by unauthorized third parties. Please do not include any sensitive or private information in any e-mail or survey responses, because such e-mail or survey responses may not be transmitted by secure means and could be intercepted by unauthorized third parties. You may opt out of receiving telephone, text message, and/or email communications at any time by contacting a Covenant Health Privacy Officer (call 865-374-8010 for more information).
Fundraising. We may use and disclose certain PHI for our fundraising activities. Such disclosures would be to associates of, or a foundation related to, the Covenant Health Entity where the patient obtained services. You have the right to opt out of receiving such communications.
Directory. A Covenant Health Entity that is a hospital or facility may maintain limited directory information (e.g., patient name, location, and general condition). The directory information may also include religious affiliation, which would be released only to clergy. Unless you object, the directory information (except for religious affiliation) will be released to those who ask for you by name. You may request that your information not be included in the directory or limit the information in the directory.
Individuals Involved in Patient Care or Payment for Care; Disaster Relief Agencies. We may release PHI to a family member or friend involved in a patient’s medical care or payment for such care. Additionally, we may release PHI to notify a family member, a friend, or a person responsible for a patient’s care of the patient’s location and general condition, and we may disclose PHI to a disaster relief agency so a patient’s family can be notified of the patient’s condition, status, and location.
Research.* We may use and disclose PHI necessary for research purposes. All research projects are subject to a special approval process that evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ right to privacy. Before we use or disclose PHI for research, the project will have been approved through this research approval process. We may, however, disclose PHI to people preparing to conduct a research project (for example, to help them look for patients with specific medical needs), so long as the medical information they review does not leave the Covenant Health Entity. In almost all other cases, we will obtain specific authorization if the researcher will have access to a patient’s name, address, or other information that reveals who the patient is. *Note. We may remove from PHI information that identifies individuals so that it may be used without learning the identity of specific patients.
As Required By Law or To Avert a Serious Threat to Health or Safety. We will disclose PHI when required by law. We also may use and disclose PHI if necessary to prevent or lessen a serious threat to a patient’s health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or lessen the threat.
Public Health Activities. We may disclose PHI for certain public health activities, including prevention or control of disease, injury, or disability; reporting births and deaths; reporting child abuse or neglect; reporting reactions to medications or problems with products; providing recall notification for products; notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; notifying employers for workplace safety purposes or to provide information regarding work-related injury or illness; and notifying the appropriate government authority if we believe a patient is the victim of abuse, neglect, or domestic violence (unless the patient is a child, has a disability, or is elderly, we generally will make this disclosure only if the patient consents).
Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure actions.
Law Enforcement. We may release PHI to law enforcement to comply with a court order, subpoena, warrant, summons or similar process authorized by law; in emergencies, to report crimes (e.g., child sexual abuse), the location of the crime or victims, or the identity, description, or location of the person who committed the crime; to comply with laws regarding the reporting of suspicious wounds and deaths; to identify a victim of a crime; to report criminal conduct on the premises of a Covenant Health Entity; and to identify or locate a suspect, fugitive, material witness, or missing person.
Lawsuits and Disputes. We may disclose PHI in response to a court or administrative order. We may also disclose PHI in response to a subpoena or other lawful process.
Specialized Government Functions. We may release PHI for specialized government functions. For example, if a patient is a member of the armed forces, we may release PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority. We may release PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may disclose PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations. If a patient is an inmate of a correctional institution or in the custody of law enforcement, we may release that patient’s PHI to such institution or to a law enforcement official.
Worker’s Compensation. We may release PHI as required by worker’s compensation or similar programs providing benefits for work-related injury or illness.
Coroners; Medical Examiners; and Funeral Directors. We may release PHI to a coroner or medical examiner. With consent or under other circumstances permitted by law, we may release PHI to funeral directors.
Organ and Tissue Donation. We may release PHI to organizations that handle organ procurement or organ, eye, or tissue transplantation.
Your rights regarding medical information about you
You have the following rights regarding the PHI we maintain about you:
Right to Inspect and Copy. You may inspect and copy PHI used to make decisions about your care. Usually, this includes medical and billing records, but does not include certain psychotherapy notes and certain other materials excepted by law. To inspect and copy PHI used to make decisions about you, you must submit your request in writing to a Covenant Health Privacy Officer (contact 865-374-8010 for more information including information on how to obtain electronic or paper copies). If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in limited circumstances. If you are denied access to PHI, you may request that the denial be reviewed. Another licensed health care professional chosen by the Covenant Health Entity will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend. If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Covenant Health Entity. To request an amendment, your request must be submitted in writing and submitted to a Covenant Health Privacy Officer (contact 865-374-8010 for more information). In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a valid reason to support the request. In addition, we may deny your request if you ask us to amend information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the PHI kept by or for the Covenant Health Entity; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.
Right to an Accounting of Disclosures. You may request an “accounting of disclosures.” This is a list of certain disclosures we made of your PHI. To request this list or accounting of disclosures, you must submit your request in writing to a Covenant Health Privacy Officer (contact 865-374-8010 for more information). Your request must state a time period that may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to a request for restrictions on uses and disclosures of PHI for treatment, payment, and health care operations purposes, except as such requests pertain to certain disclosures to health plans for purposes of payment and health care operations. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to a Covenant Health Privacy Officer (contact 865-374-8010 for more information). In your request, you must tell us what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to a Covenant Health Privacy Officer (contact 865-374-8010 for more information). We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our website, http://www.covenanthealth.com. To obtain a paper copy of this Notice, please request it from the admissions or registration area of the Covenant Health Entity treating you.
Changes to this notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for PHI we already have about you, as well as any information we receive in the future. We will post a copy of the current Notice in each Covenant Health Entity and provide you with a new notice on request. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to a Covenant Health Entity for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current Notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with the pertinent Covenant Health Entity or with the Secretary of the Department of Health and Human Services. To file a complaint with a Covenant Health Entity, contact a Covenant Health Privacy Officer (call 865-374-8010 for more information). You may also contact the Covenant Health Integrity-Compliance Department Report line at (888) 731-3115. We may request that your complaint be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of PHI not covered by this Notice or the laws that apply to the Covenant Health Entities will be made only with your written authorization. Types of uses and disclosures that may require written authorization include certain uses and disclosures of psychotherapy notes, marketing-related uses and disclosures of PHI, and sales of PHI. If you authorize us to use or disclose PHI about you, you may revoke that authorization, in writing, at any time, by providing notice of such intent to revoke to a Covenant Health Privacy Officer (call 865-374-8010 for more information). If you revoke your authorization, we will no longer use or disclose PHI about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission. Further, we are required to retain our records of the care that we provided to you.