3.1.2020
GREAT FALLS CLINIC
PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
An Organized Health Care Arrangement (OHCA) is a clinically integrated care setting, in which patients
receive health care from more than one health care provider. An OHCA can be formed between covered
entities that present themselves to the public as part of a joint arrangement. An OHCA allows legally
separate covered entities to use and disclose protected health information for the joint operation of the
arrangement. This Notice of Privacy Practices applies to the following entities, which are members of an
organized health care arrangement referred throughout this notice as the “facility”.
Great Falls Clinic, LLC
CMSC, LLC dba Great Falls Clinic Hospital
Montana Plastic Surgery Center, an affiliate of Great Falls Clinic, LLC
OHCA MEMBER OBLIGATIONS:
We are required by law to:
• Maintain the privacy of protected health information
• We will let you know promptly if a breach occurs that may have compromised the privacy or security
of your information
• Give you this notice of our legal duties and privacy practices regarding health information about you
• Follow the terms of our notice that is currently in effect
This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance
Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose
your protected health information to carry out treatment, payment or health care operations and for other
purposes that are permitted or required by law. It also describes your rights to access and control your
protected health information in some cases. Your “protected health information” means any written,
electronic or oral health information about you, including demographic data that can be used to identify
you. This is health information that is created or received by your health care provider, and that relates to
your past, present or future physical or mental health or condition. Protected health information is stored
electronically and is subject to electronic disclosure.
This Privacy Notice describes the practices of the facility(s) listed above and
• Any medical staff member and any health care professional who participates in your care;
• Any volunteer we allow to help you while you are here; and
• All employees of any hospital, clinic, laboratory, or other facility affiliated with Great Falls
Clinic, LLC, CMSC, LLC dba Great Falls Clinic Hospital, and Montana Plastic Surgery Center,
an affiliate of Great Falls Clinic, LLC.
All of these people follow the terms of this Privacy Notice. They may also share protected health
information with each other for treatment, payment or health care operations as described in this Privacy
Notice.
I. Uses and Disclosures of Protected Health Information
We may use and disclose your protected health information for purposes described below.
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A. Treatment. We may use and disclose your protected health information to provide,
coordinate, or manage your health care and any related services. This includes the coordination or
management of your health care with a third party for treatment purposes. For example, we may disclose
your protected health information to a pharmacy to fill a prescription or to a laboratory to order a blood
test. We may also disclose protected health information to physicians who may be treating you or
consulting with the facility with respect to your care. In some cases, we may also disclose your protected
health information to an outside treatment provider for purposes of the treatment activities of the other
provider.
B. Payment. We may use and disclose your protected health information to receive
payment for the care you receive from the facility. This may include certain communications to your
health insurance company to get approval for the procedure that we have scheduled. For example, we
may need to disclose information to your health insurance company to get prior approval for the surgery.
We may also disclose protected health information to your health insurance company to determine
whether you are eligible for benefits or whether a particular service is covered under your health plan. In
order to get payment for the services we provide to you, we may also need to disclose your protected
health information to your health insurance company to demonstrate the medical necessity of the services
or, as required by your insurance company, for utilization review. We may also disclose patient
information to another provider involved in your care for the other provider’s payment activities. This
may include disclosure of demographic information to anesthesia care providers for payment of their
services.
C. Operations. We may use or disclose your protected health information, as necessary, for
health care operations to facilitate the function of this facility and to provide quality care to all patients.
Health care operations include such activities as: quality assessment and improvement activities,
employee review activities, training programs including those in which students, trainees, or practitioners
in health care learn under supervision, accreditation, certification, licensing or credentialing activities,
review and auditing, including compliance reviews, medical reviews, legal services and maintaining
compliance programs, and business management and general administrative activities. In certain
situations, we may also disclose protected health information to another provider or health plan for their
health care operations.
D. Other Uses and Disclosures. As part of treatment, payment and health care operations,
we may also use or disclose your protected health information for the following purposes:
• To remind you of your medical appointments and/or surgery dates.
• We may, from time to time, contact you to provide information about treatment alternatives or
other health-related benefits and services that we provide and that may be of interest to you.
II. Other Uses and Disclosures
We may use or disclose your protected health information without your permission or authorization for a
number of reasons including the following:
A. When Legally Required. We will use and disclose your protected health information
when we are required to do so by any federal, state or local law.
B. When There Are Risks to Public Health. We may use and disclose your protected
health information for public health activities, including:
• To prevent, control, or report disease, injury or disability as permitted by law.
• To report vital events such as birth or death as permitted or required by law.
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• To conduct public health surveillance, investigations and interventions as permitted or required
by law.
• To collect or report adverse events and product defects, track FDA regulated products, enable
product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
• To notify a person who has been exposed to a communicable disease or who may be at risk of
contracting or spreading a disease as authorized by law.
C. To Report Suspected Abuse, Neglect Or Domestic Violence. We may notify
government authorities if we believe that an individual is the victim of abuse, neglect or domestic
violence. We will make this disclosure only when specifically required or authorized by law or when the
individual agrees to the disclosure.
D. To Conduct Health Oversight Activities. We may use and disclose your protected
health information for health oversight activities including audits; civil, administrative, or criminal
investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities
necessary for appropriate oversight as authorized by law. We will not disclose your health information
under this authority if you are the subject of an investigation and your health information is not directly
related to your receipt of health care or public benefits.
E. In Connection With Judicial And Administrative Proceedings. We may disclose your
protected health information in the course of any judicial or administrative proceeding in response to an
order of a court or administrative tribunal as expressly authorized by such order. In certain circumstances,
we may disclose your protected health information in response to a subpoena if we receive satisfactory
assurances that you have been notified of the request or that an effort was made to secure a protective
order.
F. For Law Enforcement Purposes. We may disclose your protected health information to
a law enforcement official for law enforcement purposes including:
• As required by law for reporting of certain types of wounds or other physical injuries.
• Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.
• For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
• Under certain limited circumstances, when you are the victim of a crime.
• To a law enforcement official if the facility has a suspicion that your health condition was the
result of criminal conduct.
• In an emergency to report a crime.
G. To Coroners, Funeral Directors, and for Organ Donation. We may disclose protected
health information to a coroner or medical examiner for identification purposes, to determine cause of
death or for the coroner or medical examiner to perform other duties authorized by law. We may also
disclose protected health information 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. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation
purposes.
H. For Research Purposes. We may use or disclose your protected health information for
research when the use or disclosure for research has been approved by an institutional review board that
has reviewed the research proposal and research protocols to address the privacy of your protected health
information.
I. In the Event of a Serious Threat to Health or Safety. We may, consistent with
applicable law and ethical standards of conduct, use or disclose your protected health information if we
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believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent
threat to your health or safety or to the health and safety of the public.
J. For Specified Government Functions. In certain circumstances, federal regulations
authorize the facility to use or disclose your protected health information to facilitate specified
government functions relating to military and veteran activities, national security and intelligence
activities, protective services for the President and others, medical suitability determinations, correctional
institutions, and law enforcement custodial situations.
K. For Worker's Compensation. The facility may release your health information to
comply with worker's compensation laws or similar programs.
L. To Business Associates. We may disclose your protected health information to third
parties known as “Business Associates” that perform various activities (e.g. legal services, delivery of
goods) for us and that agree to protect the privacy of your protected health information.
III. Uses and Disclosures Permitted without Authorization but with Opportunity to Object
Unless you object, we may disclose to your family members or others involved in your care or payment
for your care, information relevant to their involvement in your care or payment for your care or
information necessary to inform them of your location and condition. We may also disclose your
protected health information to disaster relief agencies so they may assist in notifying those involved in
your care of your location and general condition.
Unless you object, we may disclose certain information about you including your name, your general
health status and where you are in our facility in a facility directory. We may disclose this information to
people who ask for you by name, and we may disclose this information plus your religious affiliation to
clergy.
You may object to these disclosures. If you do not object to these disclosures or we can infer from the
circumstances that you do not object or we determine, in the exercise of our professional judgment, that it
is in your best interests for us to make disclosure of information that is directly relevant to the person’s
involvement with your care, we may disclose your protected health information as described.
IV. Uses and Disclosures which you Authorize
Other than as stated above, we will not disclose your health information other than with a written
authorization from you or your personal representative. You may revoke your authorization in writing at
any time except to the extent that we have taken action in reliance upon the authorization. Subject to
compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your
health information for marketing purposes or sell your health information, unless you have signed an
authorization. You may revoke an authorization by notifying us in writing, except to the extent we have
taken action in reliance on the authorization.
V. Your Rights
You have the following rights regarding your health information:
A. The right to inspect and copy your protected health information. You may inspect
and obtain a copy of your protected health information that is contained in a designated record set for as
long as we maintain the protected health information. A “designated record set” contains medical and
billing records and any other records that your surgeon and the facility uses for making decisions about
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you. We may deny your request to inspect or copy your protected health information in limited
circumstances.
To inspect and copy your medical information, you must submit a written request to the Privacy Officer
whose contact information is listed on the last page of this Privacy Notice. If you request a copy of your
information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in
complying with your request. If your information is stored electronically and you request an electronic
copy, we will provide it to you in a readable electronic form and format if it is readily producible in the
format you request.
Please contact our Privacy Officer if you have questions about access to your medical record.
B. The right to request a restriction on uses and disclosures of your protected health
information. You may ask us not to use or disclose your protected health information for the purposes of
treatment, payment or health care operations. You may also request that we not disclose your health
information to family members or friends who may be involved in your care or for notification purposes
as described in this Privacy Notice. Your request must state the specific restriction requested and to
whom you want the restriction to apply.
The facility is not required to agree to a restriction that you may request except for requests to limit
disclosures to your health plan for purposes of payment or health care operations when you have paid for
the item or service covered by the request out-of-pocket and in full and when the uses or disclosures are
not required by law. We will notify you if we deny your request to a restriction. If the facility does agree
to the requested restriction, we may not use or disclose your protected health information in violation of
that restriction unless it is needed to provide emergency treatment. You may request a restriction by
contacting the Privacy Officer.
C. The right to request to receive confidential communications from us by alternative
means or at an alternative location. You have the right to request that we communicate with you in
certain ways. We will accommodate reasonable requests. We may condition this accommodation by
asking you for information as to how payment will be handled or specification of an alternative address or
other method of contact. We will not require you to provide an explanation for your request. Requests
must be made in writing to our Privacy Officer.
D. T
he right to request amendments to your protected health information. You may
request an amendment of your protected health information if you believe such information is inaccurate
or incomplete. In certain cases, we may deny your request for an amendment. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal
to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be
in writing and must be directed to our Privacy Officer. In this written request, you must also provide a
reason to support the requested amendments.
E. T
he right to receive an accounting. You have the right to request an accounting of
certain disclosures of your protected health information made by the facility. This right applies to
disclosures for purposes other than treatment, payment or health care operations as described in this
Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that
you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family
members involved in your care, or certain other disclosures we are permitted to make without your
authorization. The request for an accounting must be made in writing to our Privacy Officer. The request
should specify the time period sought for the accounting. We are only required to maintain an accounting
of disclosures of your protected health information for six years from the date of disclosure. We will
provide the first accounting you request during any 12-month period without charge. Subsequent
accounting requests may be subject to a reasonable cost-based fee.
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F. The right to obtain a paper copy of this notice. Upon request, we will provide a separate paper
copy of this notice even if you have already received a copy of the notice or have agreed to accept this
notice electronically. You may also obtain a copy of the current version of our Privacy Notice at our
website, https://www.gfclinic.com/privacy/
VI. Our Duties
We are required by law to maintain the privacy of your health information and to provide you with this
Privacy Notice of our duties and privacy practices. If we discover a breach by us or our Business
Associates involving your unsecured protected health information, we are required to notify you of the
breach by letter or other method permitted by law. We are required to abide by terms of this Privacy
Notice as may be amended from time to time. We reserve the right to change the terms of this Privacy
Notice and to make the new provisions effective for all future protected health information that we
maintain. If we change our Privacy Notice, we will provide a copy of the revised Privacy Notice to you
or your personal representative upon request.
VII. Complaints
You have the right to express complaints to the facility and to the Secretary of the U.S. Department of
Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington, D.C.
20201, calling 1-877-696-6775,or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
if you believe that
your privacy rights have been violated. You may complain to the facility by contacting the facility’s
Privacy Officer verbally or in writing, using the contact information below. We encourage you to express
any concerns you may have regarding the privacy of your information. You will not be retaliated against
in any way for filing a complaint.
VIII. Contact Person
The facility’s contact person for all issues regarding patient privacy and your rights under the federal
privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be
requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by
this facility you may submit a complaint directly to the facility’s Privacy Officer OR to the Secretary of
the U.S. Department of Health and Human Services. The contact information is as follows:
Contact Person
Name:
Haley Denzer, MHA, CHC
Title:
Privacy & Compliance Officer
Address:
1400 29
th
Street South
Phone Number:
406.771.3126
IX. Effective Date
This Notice is effective May 15, 2020.
3.1.2020
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
I acknowledge that I have received the attached Privacy Notice.
______________________________
PRINTED Patient Name
______________________________ _______________
Patient or Personal Representative Date
Signature
If Personal Representative’s signature appears above, please describe Personal Representative’s
relationship to the patient:
__________________________________________________
For Facility use only:
If not signed, reason why acknowledgement was not obtained:____________________________
Staff Witness seeking acknowledgement
____________________________Date:______
