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Notice of Privacy Practices

CHRISTUS St. Vincent Regional Medical Center

Effective July 1, 2016

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.

Who We Are

This Notice describes the privacy practices of CHRISTUS St. Vincent Regional Medical Center, including all of our employees with access to your medical records, billing records or other information about your health care.

As used in this Notice, the term “health information” means information that identifies you. Examples include your name, date of birth, Social Security number, health care you received and details regarding the payment for your health care.

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, and to notify you in the event of a breach of your unsecured health information. We may disclose your information electronically or in any other medium. However, whenever we use or disclose your health information, we are required to abide by the terms of the Notice that is in effect at the time of the use or disclosure.

Uses and Disclosures of Your Health Information Without Your Written Authorization

In certain situations (which are described in the next section 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. For example, we may use your health information to tell you about services that are available to you or to remind you about appointments. Information may be shared with pharmacies, laboratories or radiology for the coordination of different treatments.
  2. For Payment. We may use and disclose your health information so claims for health care treatment, services, and supplies you receive from health care providers may be paid. For example, we may receive and maintain information about surgery you received to enable us to process a hospital’s claim for reimbursement of surgical expenses incurred on your behalf.
  3. Health Care Operations. We may use and disclose your health information for our health care operations, which help us do our job and operate our business. Medical residents, trainees, students and volunteers may have access to your health information for training, education and service purposes as they participate in educational programs, training, internships, resident programs, or CHRISTUS St. Vincent Regional Medical Center’s volunteer program.
  4. Facility Directory. Unless you object, your name, location in the facility, general condition and religious affiliation will be used for patient directories, in those entities where such directories are maintained. 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. Your health information is kept in an electronic format and may be electronically shared with certain CHRISTUS entities and partners. The electronic format is designed to link participating facilities so that those facilities may have access to your health information to coordinate care more easily and quickly. Participation is voluntary, unless required by law, and you may opt out of participation at any time. If you opt out, your health information will not be shared electronically with other healthcare partners. You can change your mind or withdraw consent at any time, unless disclosure is required by law; however, CHRISTUS 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 that improve the quality and cost effectiveness of the benefits that we deliver to you. We may use your health information for case management or to perform population-based studies designed to reduce health care costs. In addition, 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 might require access to your health information in order to provide such services. Examples include transcription agencies and copying services. CHRISTUS 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 close friend, family member or any other person identified by you who is involved in, or who helps pay for, your health care if you are present and do not object to the disclosure (or if it can be reasonably inferred from the circumstances, based on exercise of professional judgment, that you would not object to the disclosure).
  9. Continuity of Care. Once you have been discharged, your information may be shared with other healthcare providers such as home health agencies and community services agencies in order to obtain their services on your behalf. Also, we may use your health information to contact you with information about disease prevention and health management.
  10. Additional Uses and Disclosures. We may also use and disclose your health information without your authorization for the following purposes:
    1. As Required by Law
    2. Public Health Activities
    3. To Avoid a Serious Threat to Health or Safety
    4. Abuse, Neglect, or Domestic Violence reporting
    5. Health Oversight Agencies
    6. Notification/Disaster Relief Purposes
    7. Military, National Security, or Incarceration/Law Enforcement Custody
    8. Organ, Eye or Tissue Donation
    9. Activities related to Death
    10. Workers’ Compensation
    11. Some Research Studies
  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. Examples of these communications include: case management, care coordination, or treatment alternatives that may be available.
  12. Fundraising Communications. We may contact you to request a tax-deductible contribution to support our charitable activities. In connection with any fundraising, we may disclose to our fundraising staff, without your written authorization, your demographic information (such as your name, address and phone number), dates on which we provided health care to you, the department that treated you, the names of your treating physicians, information regarding the outcome of your treatment, and your health insurance status. You have the right to opt-out of receiving future communications with each solicitation. Information on how to opt- out will be contained in each communication.

State law may further limit the permissible ways we use or disclose your health information. If an applicable state law imposes stricter restrictions, we will comply with that state law.

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 make any disclosure of health information that is a sale of health 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 delivering a written revocation form 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 Individual 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 ask us not to use or share certain health information for treatment, payment, or our operations. 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 service or health care item out-of- pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. 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 (e.g., by email) or at alternative locations.
  4. Right to Review and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to review and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from Health Information Management and submit the completed form to Health Information Management. If you request copies, we may charge you a reasonable copy fee.
  5. Right to Amend Your Records. You have the right to request that we amend your health information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from Health Information Management and submit the completed form to Health Information Management. 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. Upon request, you may obtain an accounting of certain disclosures of your health information made by us during any period of time prior to the date of your request provided such period does not exceed six years. 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. Your personal representative must complete a Personal Representative Form. We reserve the right to deny access to your personal representative.
  8. For Further Information; 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. 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:



Jennifer Gomez, Vice President, Corporate Compliance
CHRISTUS St. Vincent Regional Medical Center
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, in our office, and on our web site at