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Notice of Privacy Practices

CHRISTUS St. Vincent Regional Medical Center

Effective April 15, 2021

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.

If you have any questions, please contact the Privacy Office at the address or phone number at the end of this Notice.

Your Privacy is Important to CHRISTUS St. Vincent

CHRISTUS St. Vincent understands how important your personal medical information is to you. We protect the privacy of your health information because it is the right thing to do. We also follow federal and state laws that govern your health information. We use your health information (and allow others to have it) only as permitted by federal and state laws. These laws give you certain rights regarding your health information. This Notice describes the privacy practices of CHRISTUS St. Vincent, including all of our workforce members with access to your health information.

Our Privacy Obligations

We understand that your health information is personal and we are committed to protecting your privacy. In addition, we are required by law to maintain the privacy of your health information, to provide you with this Notice of our legal duties and privacy practices with respect to your health information, to communicate your health information rights and to notify you in the event of a breach of your unsecured health information.

CHRISTUS St. Vincent provides health care to our patients in partnership with many physicians and other professionals and organizations. CHRISTUS St. Vincent, the members of its medical staff and other affiliated health care providers that offer clinically integrated health care participate in an Organized Health Care Arrangement (OHCA). The OHCA members share information for treatment, payment and healthcare operations to improve, manage and coordinate your care for joint health care activities. This notice applies to these health care providers as part of the OHCA. However, this notice only applies to the privacy practices of these health care providers when they are providing care at CHRISTUS St. Vincent. It does not apply to the privacy practices of these providers in their own offices or other health care settings.

Uses and Disclosures of Your Health Information Without Your Written Authorization

When we care for you, we will gather your health information. In certain situations (described below) we must obtain your authorization in order to use and/or disclose your health information. However, we may use and disclose your health information without your authorization for the following purposes:

  1. For Treatment. We may use or disclose your health information to help with your health care including:
    1. Appointment reminders
    2. Possible treatment options and health-related benefits, disease prevention or services that may be of interest to you
    3. Sending your information to a specialist as part of a referral
    4. Sharing information with pharmacies, laboratories or radiology for the coordination of different treatments
  2. For Payment. We may use and disclose your health information to receive payment for health care treatment, services, and supplies you receive from health care providers.
  3. Health Care Operations. We may use and disclose your health information for our health care operations, to help us operate our business including sharing information with medical residents, trainees, students for training and education purposes and partnering with volunteers to support our volunteer program.
  4. Facility Directory. Unless you object, your name, location in the facility, general condition and religious affiliation will be used in our patient directory. This information, except for religious affiliation, may be provided to people who ask for you by name. Religious affiliation may be provided to members of the clergy.
  5. Health Information Exchange (HIE). CHRISTUS St. Vincent participates in a health information exchange (HIE). HIE provides a way to securely and electronically share patients’ clinical information with other health care providers participating in the HIE network to provide safer, more timely, efficient and higher quality care. You may opt out of participation at any time. If you opt out, your health information will not be further shared through the HIE. You can change your mind or withdraw consent at any time, unless disclosure is required by law; however, CHRISTUS St. Vincent cannot take back information that has already been shared.
  6. Quality Improvement. We may use and disclose your health information for internal administration and planning and various activities for improving the quality and cost effectiveness of the care that we deliver to you. We may use your health information for care management or to perform population-based studies designed to reduce health care costs. We may use or disclose your health information to conduct compliance reviews, audits, and/or for fraud and abuse detection. We are prohibited from using or disclosing your genetic information for underwriting purposes.
  7. To a Business Associate. Certain services are provided to us through contracts with third party entities known as “business associates” that require access to your health information in order to provide such services. CHRISTUS St. Vincent requires these business associates to appropriately protect your health information in compliance with all laws.
  8. Family and Friends. We may disclose your health information to a friend or family member who is involved in your medical care, helps pay for your care or for notification of your location and condition during disasters or emergencies.
  9. Continuity of Care. For your ongoing health care management, your information may be shared with other health care providers such as home health agencies, health care suppliers and community services agencies in order to obtain their services on your behalf. These care continuity activities help improve health care outcomes, patient satisfaction and overall quality of care.
  10. Required Uses of Health Information. The law sometimes requires and/or permits us to share information for specific purposes, with:
    1. Public Health Agencies to report public health activities such as communicable diseases, traumatic injuries, or birth defects, or for vital statistics, such as a baby’s birth.
    2. Activities related to death such as a funeral director or an organ- donation agency or with a medical examiner to investigate a death.
    3. The appropriate governmental agency, if an injury or unexpected death occurs at our facility.
    4. State authorities, to report child or elder abuse.
    5. Law enforcement, for certain types of crime-related injuries.
    6. Governmental inspectors/agencies to make sure our facilities are safe or to report a breach of health information privacy.
    7. Military command authorities or the Department of Veterans Affairs, when we treat patients that are in the military or veterans.
    8. A correctional institution, if a patient is an inmate.
    9. The Secret Service or NSA, to protect the country or President.
    10. A medical device’s manufacturer, as required by the FDA.
    11. Court officers, as required by law, in response to a court order or a valid subpoena.
    12. Governmental authorities, to prevent serious threats to the public’s health or safety.
    13. A worker’s compensation program, if a person is injured at work and claims benefits under that program.
  11. Marketing. We may only use your health information for limited marketing purposes as follows: face-to-face communications, promotional gifts of nominal value, refill reminders, or to otherwise tell you about a drug related to your treatment or our healthcare operations as described in this Notice.
  12. Fundraising Communications. We may use your name, address, age, date of birth, gender, dates of service, department of service, treating physician, outcome information and health insurance status to raise funds for CHRISTUS St. Vincent. We may contact you to request a tax-deductible contribution to support our charitable activities. You have the right to opt-out of receiving fundraising communications with each solicitation. Information on how to opt-out will be contained in each communication.
  13. Research. We may use or disclose your PHI to conduct health care research as authorized by law. We may also de-identify your health information as permitted by HIPAA. We may use or disclose to others the de-identified information for any purpose, without your further authorization or consent.

Uses and Disclosures that Require Your Written Authorization

For any purpose other than the ones described above, we only use or disclose your health information when you give us your written authorization.

  1. Sale of Health Information. We will not disclose your health information for the purposes of selling your information without your written authorization.
  2. Psychotherapy Notes. We will not use or disclose psychotherapy notes about you without your authorization except for use by the mental health professional who created the notes to provide treatment to you, for our mental health training programs or to defend ourselves in a legal action or other proceeding brought by you.
  3. Revocation of Your Authorization. You may revoke your authorization at any time by completing a written revocation form and submitting it to our Privacy Office. If you revoke your authorization, we will no longer use or disclose your health information except as described above (or as permitted by any other authorizations that have not been revoked). However, your revocation will not be effective with respect to any health information previously disclosed to a third party in reliance on your prior authorization.

Your Health Information Rights

  1. Right to Receive this Notice of Privacy Practices. You have the right to receive a copy of this Notice at any time. You may obtain a paper copy of the current notice in all clinical areas or an electronic copy by visiting our website.
  2. Right to Request Restrictions. You can request in writing that restrictions be placed on how your health information is used or shared for treatment and other purposes. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a health care service item out-of-pocket in full, you can ask us not to share that information with your health insurer for the purpose of payment or operations. We will say “yes” unless a law requires us to share that information.
  3. Right to Receive Communications by Alternative Means or at Alternative Locations. You may request, and we will accommodate, any reasonable written request for you to receive your health information by alternative means of communication or at alternative locations.
  4. Right to Review and Copy Your Health Information. You may request to inspect and obtain a copy of your medical or billing records (including an electronic copy if we maintain the records electronically), as allowed by law, usually within 30 days of your written request. We may charge you a reasonable fee.
  5. Right to Amend Your Records. You may request in writing that your health information be amended if you think there is an error. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
  6. Right to Receive An Accounting of Disclosures. You may request an accounting of certain disclosures when your identifiable health information is shared outside of CHRISTUS St. Vincent for a purpose other than treatment or payment. If you request an accounting more than once during a twelve (12) month period, we may charge you a reasonable fee for the accounting statement.
  7. Personal Representatives. You may exercise your rights through a personal representative, as permitted under our health information privacy policy, and as determined under applicable state law. We reserve the right to deny access to your personal representative, as permitted by law.
  8. Notice of Breach. You will receive notice if we or our business associates have breached the confidentiality of your unsecured health information.
  9. For Further Information or Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your health information, you may contact our Privacy Office. Be assured that we will investigate your concern thoroughly, support you appropriately, and not retaliate against you in any way. You may also file written complaints with the Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Office for Civil Rights. We will not retaliate against you if you file a complaint with us or with the Office for Civil Rights.

Privacy Office Contact Information

If you have a question, concern, or complaint regarding how your health information is protected, used, and/or disclosed, you may contact the Privacy Office by any of the following means:


Phone: CHRISTUS St. Vincent Integrity Line (toll free) 1-877-888-4812

Mail: Privacy Officer c/o CHRISTUS St. Vincent Compliance Dept.
455 St. Michael’s Drive, Santa Fe, NM 87505

Right to Change Terms of this Notice

We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request and on our web site at: