Our pledge to protect your privacy
At Tuality Healthcare and Tuality/OHSU Cancer Center (“Tuality”), we understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Tuality. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by any health care professional authorized to enter information into your personal healthcare record. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have about the use and disclosure of medical information.
Tuality and other medical providers are required by law to maintain the privacy of your medical information. We also are required to notify you of our legal duties and privacy practices regarding your medical information, and abide by the practices described in this notice.
Who will follow this notice?
The following individuals and organizations share our commitment to protect your privacy and will comply with this notice:
- Any health care professional authorized to enter information into your medical record.
- Members of our medical staff, employees, volunteers, trainees, students and other healthcare personnel who provide services at Tuality or affiliated patient care settings listed below.
- All of Tuality Healthcare’s entities, departments and units (Tuality Community Hospital, Tuality Forest Grove Hospital, Tuality Healthcare Foundation, and Tuality Medical Equipment and Supply).
- Patient care settings affiliated with Tuality, and all medical staff, employees, volunteers, trainees, students, or other personnel providing services in these patient care settings. These Tuality patient care settings include: the hospitals, home health, outpatient services, rehabilitation services, urgent care, medical equipment rental and supply, managed physician’s offices, and our affiliates (Tuality/ OHSU Cancer Center, Tanasbourne Medical Plaza, Tuality Health Alliance, Raines Dialysis Center).
Note: Tuality may provide services to you in an integrated way with our medical staff and the affiliated patient care settings referenced above. However, Tuality accepts no legal responsibility for activities solely attributable to these other providers or care settings.
How we may use and disclose your medical information
Members of our medical staff, appropriate hospital employees, and other participants in our patient care system may share your medical information without your express permission, as necessary for:
- Your treatment;
- Payment for your services provided;
- Health care operations.
Other uses require your specific authorization. The following describes how we may use and disclose your information without express permission. Other parts of this notice describe uses and disclosures that require your authorization, and the rights you have to restrict our use and disclosure of your medical information.
Primary uses and disclosures allowed without your express permission
This section discusses the requirements of federal privacy laws. Oregon law provides additional protections in some circumstances.
For treatment. We are permitted to use and disclose your medical information within Tuality and its affiliates as necessary to provide you with medical treatment and services. For example:
- A doctor treating you for a broken leg may need to know if you have diabetes because the disease may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals.
- Different Tuality departments may also share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
- Your doctor may be treating you for a heart condition and may need to know if you have other health problems that could complicate your treatment. The doctor may use your medical history to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help provide care or consultation to determine the most appropriate care for you. On occasion, we may need to communicate with your physician’s answering service in order to expedite your care and to provide timely information for a physician who is “on-call.”
- We also may disclose medical information about you to people outside Tuality who may be involved in your medical care after you leave Tuality, such as long-term care facilities, personal caregivers, or home health agencies.
For payment. We are permitted to use and disclose medical information about you so that the treatment and services you receive at Tuality may be billed to you and so that payment may be collected from you, an insurance company, health plan, or other third-party payer. For example:
- We may need to give your health plan information about a service you receive here, so we may be paid or reimburse you for the service.
- We may also tell your health plan about a treatment you are going to receive, to determine whether your health plan will cover the service.
- We may release medical information to emergency responders to allow them to obtain payment or reimbursement for services provided to you.
For health care operations We are permitted to use and disclose medical information about you so that the treatment and services you receive at Tuality may be billed to you and so that payment may be collected from you, an insurance company, health plan, or other third-party payer. For example:
- We are permitted to use and disclose medical information about you for our own organization’s operations. These uses and disclosures are necessary to run Tuality and our affiliates and make sure that all of our patients receive quality care.
- We also are permitted to disclose your medical information for the health operations of another health care provider or health plan, as long as they have a relationship with you and need the information for their own quality assurance purposes, for purposes of reviewing the qualifications of their health care professionals, or conducting skill improvement programs.
- We may use your medical information to ensure we are complying with all federal and state compliance requirements.
- We also may disclose your medical information to a community physician to assist the physician in assessing the quality of care provided in your case and for other similar purposes.
Other uses and disclosures allowed without your express permission
Research when approved by an Institutional Review Board.
Under certain circumstances, we may use and disclose medical information about you for research purposes. Your medical information would only be available if you had signed a consent to participate in the research project. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process through an Institutional Review Board. Before we use or disclose medical information for research without your authorization, the project will have been approved through this research approval process.
As required by law.
We will disclose medical information about you when required to do so by federal, state or local law. (See Public Health Risks below.)
To support public health activities.
These activities typically include reports to such agencies as the Oregon Department of Human Services as required or authorized by state law. These reports may include, but are not necessarily be limited to, the following:
- To prevent or control disease, injury or disability;
- To report births and deaths;
- To report suspected child abuse or neglect;
- To report suspected elderly abuse or neglect;
- To report reactions to medications or problems with products;
- To notify people of recalls of products they may be using;
- 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.
Organ and tissue donation.
We may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Donations cannot occur without consent.
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 may also release medical information about foreign military personnel to the appropriate foreign military authority.
We will only release medical information about you for Workers’ Compensation or similar programs in accordance with applicable law. These programs provide benefits for work-related injuries or illness.
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.
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.
We may release medical information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- To report suspected elderly abuse or neglect;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at Tuality;
- 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 medical 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 patients of Tuality to funeral directors as necessary for them 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 of the United States 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 so they may conduct special investigations.
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: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
When required 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.
As required by federal, state or local law.
We will disclose medical information about you when required to do so by federal state or local law.
Certain incidental disclosures of your medical information occur as a byproduct of lawful and permitted use and disclosure of your medical information. For example, a visitor may inadvertently overhear a discussion of your care occurring at the nurses station. These incidental disclosures are permitted if we apply reasonable safeguards to protect your medical information.
Limited data set information.
We may disclose limited health information to third parties for purposes of research, public health and healthcare operation purposes. This health information includes only the following identifiers:
- Admission, discharge, and service dates;
- Five-digit ZIP Code or any other geographic subdivision, such as state, county, city, precinct and their equivalent geocodes (except street address).
Before disclosing this information, we must enter into an agreement with the recipient of the information that limits who may use or receive the data, and that requires the recipient to agree not to re-identify the data or contact you. The agreement must contain assurances that the recipient of the information will use appropriate safeguards to prevent inappropriate use or disclosure of the information.
Oregon Law: Oregon law provides additional confidentiality protections in some circumstances. For example, in Oregon a health care provider generally may not release the identity of a person tested for HIV or the results of an HIV-related test without your consent and you must be notified of this confidentiality right. Drug and alcohol records are specially protected and typically require your specific consent for release under both federal and state law. Mental health records are specially protected in some circumstances, as is genetic information.
For more information on Oregon law related to these and other specially protected records, please contact our Privacy Officer, or refer to the Oregon Revised Statutes and the Oregon Administrative Rules. These documents are available on-line at www.oregon.gov
Uses and disclosures allowed unless you object
Appointment reminders.We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at Tuality or an affiliated clinic.
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 information about you to contact you in an effort to raise money for Tuality and its operations. We may disclose medical information to the Tuality Healthcare Foundation so that they may contact you. These may include contact information, such as your name, address, phone number, and when you received treatment. If you do not want Tuality to contact you for fundraising purposes, you must notify our Privacy Officer in writing.
Hospital directory.We may include limited information about you in Tuality’s directory while you are a patient in the hospital. This information may include your name, location in the hospital, general condition (e.g., fair, serious, etc.), and religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you at Tuality and generally know how you are doing. 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. If you do not want us to make these disclosures, you must notify the Privacy Officer in writing.
Family or friends involved in your care.Health professionals, using their best judgment, will disclose to a family member or close personal friend, or anyone else you identify, medical information relevant to that person’s involvement in your care. We may also give information to someone who helps pay for your care. If you do not want us to make these disclosures, you must notify our Privacy Officer in writing.
Uses and disclosures that require your authorization
Other uses and disclosures for purposes other than described above require your express authorization. For example, we must obtain your authorization before disclosing your medical information to a life insurance company or to an employer, except under special circumstances such as when disclosure to the employer is required by law. You have the right to revoke an authorization at any time, except to the extent we have already relied on it to make an authorized use of disclosure. Your revocation of an authorization must be in writing and addressed to the Privacy Officer.
Tuality hopes that if you choose to revoke an authorization, you will help us comply with your wishes by identifying the authorization you are choosing to revoke. Ways of telling us which authorization you are revoking might include indicating who you authorized to receive information and the approximate timeframe in which you signed the authorization.
Disclosures to business associates
Tuality contracts with outside companies that perform business services for us, such as billing companies, management consultants, quality assurance reviewers, accountants or attorneys. In certain circumstances, we may need to share your medical information with a business associate so it can perform a service on our behalf. Tuality will limit the disclosure of your information to a business associate to the amount of information that is the minimum necessary for the company to perform the contracted services. In addition, we will have a written contract in place with the business associate requiring it to protect the privacy of your medical information.
You have the right:
To request, to inspect, and receive a copy. You have the right to inspect and receive a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes that are not a part of the legal record.
- To inspect and receive a copy of your medical information you must submit your request in writing to:
Tuality Healthcare Medical Records Department
Release of Information Desk
335 SE 8th Ave.
Hillsboro, OR 97123
If you request a copy of the information, we may charge a fee for the costs of copying, mailing or supplies associated with your request. 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.
- We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Tuality 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.
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 on behalf of Tuality.
To request an amendment, your request must be made in writing and submitted to the Privacy Officer. 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 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 medical information kept by or on behalf of Tuality;
- Is not part of the information which you would be permitted to inspect and copy;
- Is accurate and complete.
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 health care 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 a surgery you had. To request a restriction you must put your request in writing. 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 you emergency treatment.
To request restrictions, you must make your request in writing to:
335 SE 8th Ave.
Hillsboro, OR 97123
In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
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 may ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to:
335 SE 8th Ave.
Hillsboro, OR 97123
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 at any time at most Tuality registration desks. You may download a copy of this notice here.
Right to an accounting of disclosures. You may request, in writing, an accounting of disclosures we made of your medical information in the previous six years, beginning April 14, 2003. You are entitled to an accounting of disclosures we made of medical information about you to others except for purposes of treatment, payment and operations, disclosures you authorized, disclosures to you, incidental disclosures, disclosures to family or other persons involved in your care, disclosures to correctional institutions and law enforcement in some circumstances, disclosures of limited data set information or disclosures for national security or law enforcement purposes.
To request this list or accounting of disclosures for Tuality services provided to you, you must submit your request in writing to:
Medical Records Department
Release of Information Desk
335 SE 8th Ave.
Hillsboro, OR 97123
Or, for services provided at your physician’s office, contact your physician directly.
Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. 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.
Changes to this notice
We reserve the right to change this notice. We reserve the right to make the revised notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice at Tuality Community Hospital, Tuality Forest Grove Hospital, and Tuality/OHSU Cancer Center. The notice will contain the effective date identified on the first page of this document.
If you believe your privacy rights have been violated, you may file a complaint with:
335 SE 8th Ave.
Hillsboro, OR 97123
Region X, Office for Civil Rights
U.S. Department of Health and Human Services
2201 Sixth Ave., Suite 900
Seattle, WA 98121-1831
Or you may call 206-615-2287 or fax 206-615-2297. Or you may file a complaint by e-mail to OCRComplaint@hhs.gov.
You will not be penalized for filing a complaint.