Humboldt General Hospital's HIPAA Website
What does "HIPAA" stand for?
"HIPAA" is the acronym for the federal legislation titled
Act of 1996.
Who must comply with HIPAA?
HIPAA is applicable to:
- Health Care Providers (who transmit electronic transactions covered by
the HIPAA regulations)
- Health Plans (self-insured/insured, HMOs, health insurance companies, employer
health plans, and similar arrangements)
- Health Care Clearinghouses
Those who must comply with HIPAA are considered "covered entities."
What does HIPAA do?
Without question, HIPAA is complex and has many components, but basically
it addresses 3 major areas:
- Privacy - provides new rules in regard to how an individual's health
information may be used and disclosed by covered entities.
- Transaction and Code Sets - requires the use of standard transaction formats
and code sets when an individual's financial health information is
transmitted electronically by a covered entity for purposes of payment,
coverage determinations, eligibility determinations, and similar business matters.
- Security - requires covered entities to have specific security measures
in place to protect an individual's health information that is sent
or stored electronically.
Our Pledge Regarding Your Medical Information
Humboldt General Hospital is dedicated to protecting your personal medical
information. When you receive care at HGH we create a record set necessary for:
- your treatment;
- our payment actions related to your treatment; and
- management of our health care operations related to your treatment.
Health records may be created by Humboldt General Hospital personnel or
by a doctor or other licensed professional who treats you at HGH but who
is not an HGH employee. Non-employee doctors and other licensed professionals
may have different policies or notices regarding use and disclosure of
your medical information created in their private offices or clinics.
They are responsible to provide you with their Notice of Privacy Practices.
Required by Law
This notice applies to how we may use and disclose your medical records
while you are receiving care at Humboldt General Hospital. It also describes
your rights with respect to your personal medical information. We are
required by law to:
- make sure that medical information that identifies you is kept private;
- give you this notice that describes why and how we may use or share your
- have you sign a form signifying you received a copy of the notice; and
- follow the terms of this notice on its effective date and thereafter until modified.
There may be circumstances when state law supersedes HIPAA, for example
HIV, Drug and Alcohol, and Mental Health information. In these situations,
we will follow the provisions of the specific state law.
How We May Use and Disclose Medical Information About You
The following categories describe different ways we use and disclose medical
information. For each category of uses or disclosures we explain what
we mean and give some examples. All of the ways we use and disclose information
will fall within one of the categories:
- For Treatment: We may use and disclose medical information about you to
another party on your behalf so that we can get paid for the treatment
and services you receive at Humboldt General Hospital. We may disclose
medical information about you to doctors, nurses, technicians, medical
students, or other HGH personnel who are involved in taking care of you.
For example, a doctor treating you for depression may need to know if
you have other health conditions that might be related to your depression.
Also, different departments at HGH may share your medical information
in order to coordinate the different things you need, such as prescriptions
and lab work. We also may disclose medical information about you to people
outside Humboldt General Hospital who may be involved in your health care
after you leave HGH, such as family members or others we use to provide
services that are part of your care.
- For Payment: We may use and disclose medical information about you so that
the treatment and services you receive at Humboldt General Hospital may
be billed to and payment collected from you or another party on your behalf.
For example, we may need to give your health plan information about treatment
that you received at HGH so your health plan will pay us for the treatment.
We also may tell your health plan about a treatment you are going to receive
to obtain prior approval or to determine whether your plan will cover
- For Health Care Operations: We may use and disclose your medical information
for Humboldt General Hospital operations. Such uses and disclosures are
necessary to run HGH and to make sure all of our clients receive quality
care. For example, we may use medical information to review our treatment
and services and to evaluate the performance of our staff in caring for
you. We may also combine medical information about many HGH clients to
decide what additional services we should offer, what services are not
needed, and if certain new treatments are effective. We also may disclose
information to doctors, nurses, technicians, medical students, and other
HGH personnel for review and learning purposes. We may remove information
that identifies you from this set of medical information so others may
use it to study health care and health care delivery without knowing that
your information is included.
- Appointment Reminders: We may use and disclose medical information to contact
you as a reminder that you have an appointment for treatment at Humboldt
- Treatment Alternatives: We may use and disclose medical information to
tell you about or recommend possible treatment options or alternatives
that may be of interest to you.
- Health-Related Benefits and Services: We may use and disclose medical information
to tell you about health-related benefits or services that may be of interest to you.
- Fundraising Activities: We may use your medical information to contact
you in an effort to raise money for Humboldt General Hospital and its
operations. We may disclose contact information to a foundation related
to HGH so that the foundation may contact you in raising money for Humboldt
General Hospital. Contact information consists of your name, address and
phone number and the dates you received treatment or services at HGH.
If you do not want Humboldt General Hospital to contact you for fundraising,
you must notify the Office of the Administrator at 118 E. Haskell Street,
Winnemucca, Nevada 89445 in writing.
- Individuals Involved in Your Care or Payment for Your Care: We may release
medical information about you to designated parties who are involved in
your care. We also may give information to someone who helps pay for your
care. In addition, we may disclose medical information about you to an
entity assisting in a disaster relief effort so that your family can be
notified about your condition, status and location.
- Research: Under certain circumstances, we may use and disclose medical
information about you for research purposes. For example, a research project
may involve comparing the health and recovery of all clients with the
same condition who received one medication to those who received another
medication. All research projects are subject to a special approval process.
This process evaluates a proposed research project and its use of medical
information to ensure client medical information is only used and disclosed
as necessary for the research project. Normally we use or disclose medical
information for research only after the project has been approved through
the research approval process. However, we may disclose medical information
about you to researchers to help them identify clients with specific medical
needs. In these pre-research actions, we will not allow researchers to
copy or otherwise transmit your medical information outside Humboldt General
Hospital. Also we will most often ask for your authorization if the researcher
will have access to your name, address or other information that reveals
who you are, or will be involved in your care at HGH.
- As Required By Law: We will disclose medical information about you when
required to do so by federal, state or local law.
- To Avert a Serious Threat to Health or Safety: We may use and disclose
medical information about you when necessary to prevent a serious threat
to your 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 the threat.
Special Situation for Release of Medical Information
- Military and Veterans: If you are a member of the armed forces, we may
release medical information about you as required by military command
authorities. We also may disclose medical information about you to the
Department of Veterans Affairs upon your separation or discharge from
military services. This disclosure may be necessary for the Department
of Veterans Affairs to determine if you are eligible for certain benefits.
- Workers' Compensation: We may release medical information about you
for workers' compensation or similar programs. These programs provide
benefits for work-related injuries or illness.
- Public Health Risks: We may disclose medical information about you for
public health activities. These activities generally include the following:
(i) To prevent or control disease, injury or disability; (ii) To report
births and deaths; (iii) To report child abuse or neglect; (iv) To report
reactions to medications or problems with products; (v) To notify people
of recalls of products they may be using; (vi) To notify a person who
may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition; or, (vii) To notify the appropriate
government authority if we believe a patient has been the victim of abuse,
neglect or domestic violence. We will only make this disclosure when required
or authorized by law or if you authorize such disclosure.
- Health Oversight Activities: We may disclose medical information to a health
oversight agency for activities authorized by law.
These oversight activities include, for example:
Audits, investigations, inspections, and licensure. These activities are
necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
- Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we
may disclose medical information about you in response to a court or administrative
order. We may also disclose medical information about you in response
to a subpoena, discovery request, or other lawful process by someone else
involved in the dispute, but only if efforts have been made to tell you
about the request or to obtain an order protecting the information requested.
- Law Enforcement: We may release medical information if asked to do so by
a law enforcement official: (i) In response to a court order, subpoena,
warrant, summons or similar process; (ii) To identify or locate a suspect,
fugitive, material witness, or missing person; (iii) About the victim
of a crime if, under certain limited circumstances, we are unable to obtain
the person's agreement; (iv) About a death we believe may be the result
of criminal conduct; (v) About criminal conduct at HGH; and, (vi) In emergency
circumstances to report a crime; the location of the crime or victims;
or the identity, description or location of the person who committed the crime.
- Coroners, Medical Examiners and Funeral Directors: We may release health
information to a coroner or medical examiner. This may be necessary, for
example, to identify a deceased person or determine the cause of death.
We may also release medical information about a deceased person to funeral
directors as necessary to carry out their duties.
- National Security and Intelligence Activities: We may release medical information
about you to authorized federal officials for intelligence, counterintelligence,
and other national security activities authorized by law.
- Protective Services for the President and Others: We may disclose medical
information about you to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads
of state or conduct special investigations.
- Inmates: If you are an inmate of a correctional institution or under the
custody of a law enforcement official, we may release medical information
about you to the correctional institution or law enforcement official.
This release would be necessary for the following: (i) For the institution
to provide you with health care; (ii) To protect your health and safety
or the health and safety of others; or, (iii) For the safety and security
of the correctional institution.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice
or the laws that apply to us will be made only with your prior, fully
informed, written authorization. If you provide us authorization to use
or disclose medical information about you, you may revoke the authorization
at any time by giving us written instructions to revoke. If so instructed,
we will no longer use or disclose medical information about you for the
reasons covered by the authorization you revoke. We will be unable to
take back any disclosures already made prior to the authorization being
revoked. We also are required to retain in your medical records such disclosures
as may have been made during the time the authorization was in effect.
Your Rights Regarding Medical Information
You have the following rights regarding medical information we maintain
- Right to Inspect and Copy: You have the right to inspect and copy your
medical information that may be used to make decisions about your care.
Usually, this includes medical and billing records, but does not include
any psychotherapy notes maintained by your provider. To inspect and copy
medical information that may be used to make decisions about you, you
must submit your request in writing to the Office of the Administrator.
If you request a copy of the information, Humboldt General Hospital may
charge a fee for the costs of copying, mailing or other supplies associated
with your request. We may deny your request to inspect and copy your medical
information in certain very limited circumstances. If you are access to
your medical information you may appeal the denial. Your appeal will be
considered by a licensed health care professional chosen by HGH and not
previously involved in the denial of your original request for denied
inspection and copy. Humboldt General Hospital will abide by the decision
of the appeal reviewer.
- Right to Amend: If you feel that medical information 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 Humboldt General Hospital. To request an amendment,
you must make it in writing and submit it to the Office of the Administrator.
You must provide justification and documentation that supports your amendment
request. We may deny your request for an amendment if it is not in writing
or does not include justification and documentation to support the request.
In addition, we may deny your request if you ask us to amend information
that: (i) Was not created by us, unless the person or entity that created
the information is no longer available to make the amendment; (ii) Is
not part of the information kept by or for HGH; (iii) Is not part of the
information which you would be permitted to inspect and copy; or, (iv)
Is accurate and complete.
- Right to an Accounting of Medical Information Disclosures: We keep a record
of every time we share your medical information for purposes other than
treatment, payment and operations. We generally classify these types of
disclosures as "non-routine" and we control and track such disclosures.
We do not maintain a record of disclosures made when you have given written
authorization for such disclosures. To request an accounting of these
"non-routine" disclosures, you must submit your request in writing
to the Office of the Administrator. Your request must state a time period
which may not be longer than six years and may not include dates before
January 1, 2004. Your request also should indicate in what form you want
the accounting (for example, on paper, electronically). The first accounting
you request within a twelve (12) month period will be provided free of
charge. For additional accountings within the same twelve (12) month period,
we may charge you for the costs of providing the accounting. 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 medical information we use or disclose about you
for treatment, payment or operations. You also have the right to request
a limit on the medical information we disclose about you to someone who
is involved in your care or the payment for your care, like a family member
or friend. For example, you could ask that we not use or disclose information
about your treatment at Humboldt General Hospital to your family members.
To request restrictions, you must make your request in writing to the
Office of the Administrator. In your request, you must tell us: (i) What
information you want us to limit; (ii) Whether you want to limit our use,
disclosure or both; and, (iii) To whom you want the limits to apply; for
example, disclosures to your family. We are not required to agree to your
request. If we do agree, we will comply with your request unless the information
is needed to provide emergency treatment to you.
- Right to Request Confidential Communications: You have the right to request
that we communicate with you about health 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 the Office of the Administrator. Your request
must specify how or where you wish to be contacted. You do not have to
provide the reason for your request. Humboldt General Hospital will accommodate
all reasonable requests.
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. To obtain another paper copy of this notice, contact the Office
of the Administrator. You may obtain an electronic copy of this notice
at our website,
www.hghospital.ws. Even if you have an electronic version of the Notice, you are still entitled
to a paper copy if you want one.
The HIPAA Privacy Rule gives individuals a fundamental new right to be
informed of the privacy practices of their health plans and of most of
their health care providers, as well as to be informed of their privacy
rights with respect to their personal health information. Health plans
and covered health care providers are required to develop and distribute
a notice that provides a clear explanation of these rights and practices.
The notice is intended to focus individuals on privacy issues and concerns,
and to prompt them to have discussions with their health plans and health
care providers and exercise their rights.
How the Rule Works
General Rule. The Privacy Rule provides that an individual has a right
to adequate notice of how a covered entity may use and disclose protected
health information about the individual, as well as his or her rights
and the covered entity's obligations with respect to that information.
Most covered entities must develop and provide individuals with this notice
of their privacy practices. The Privacy Rule does not require the following
covered entities to develop a notice:
- Health care clearinghouses, if the only protected health information they
create or receive is as a business associate of another covered entity.
See 45 CFR 164.500(b)(1).
- A correctional institution that is a covered entity (e.g., that has a covered
health care provider component).
- A group health plan that provides benefits only through one or more contracts
of insurance with health insurance issuers or HMOs, and that does not
create or receive protected health information other than summary health
information or enrollment or disenrollment information.
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 medical information we already
have about you as well as any medical information we create in the future.
We will post a copy of the current notice at appropriate client access
points in our treatment facilities. The notice will contain its effective
date on the top of the first page. In addition, each time you register
at or are admitted to Humboldt General Hospital for treatment or health
care services as an inpatient or outpatient, we will ask you if you want
a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint
with Humboldt General Hospital, Office of the Administrator, at:
118 E. Haskell Street
Winnemucca, Nevada 89445
All complaints must be submitted in writing. Your complaint actions will
be held in the strictest confidence. Humboldt General Hospital will not
take any actions to discourage you from filing a complaint nor will we
act against you in any way because of filing a complaint.