Privacy Policies & Disclaimers
LAKELAND REGIONAL HEALTH SYSTEM
NOTICE OF PRIVACY
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
I. Understanding Your Health Record Information.
Each time you visit a hospital, physician or other healthcare provider, the
provider makes a record of it. Typically, this record contains your health
history, current symptoms, examination and test results, diagnoses, treatment
and a plan for future care or treatment. This information, often referred to as
your medical record, serves as a:
A. Basis for planning your care and treatment.
B. Means of communication among the many health professionals who contribute
to your care.
C. Legal document describing the care you received.
D. Means by which you or a third-party payer can verify that you actually
received the services billed.
E. Tool in medical education.
F. Source of information for public health officials charged with improving
the health regions they serve.
G. Tool to assess the appropriateness and quality of care you received.
H. Tool to improve the quality of healthcare and achieve better patient
Understanding what is in your health records and how your health information
is used helps you to:
I. Ensure its accuracy and completeness.
J. Understand who, what, where, when, why and how others may access your
K. Make informed decisions about authorizing disclosure to others.
L. Better understand the health information rights detailed below. (See
II. We Have a Legal Duty to Safeguard Your Protected Health
We are legally required to protect the privacy of your health information.
We call this information "protected health information," or "PHI" for short. It
includes information that can be used to identify you, that we’ve created or
received about your past, present, or future health or condition, the provision
of health care to you, or the payment of health care. We must provide you with
this notice about our privacy practices that explains how, when, and why we use
and disclose your health information. With some exceptions, we may not use or
disclose any more of your health information than is necessary to accomplish the
purpose of the use or disclosure. We are legally required to follow the privacy
practices that are described in this notice.
Lakeland Regional Health System (LRHS) and all of its subsidiaries will abide
by the LRHS Notice of Privacy Practices. All credentialed medical staff of LRHS
and its subsidiaries will abide by the LRHS Notice of Privacy Practices while
operating at an LRHS entity. The LRHS Notice of Privacy Practices will not cover
the credentialed medical staff in their individual office practices. An
Organized Health Care Arrangement (OHCA) is a clinically integrated
arrangement in which patients are treated by two or more health care providers.
All members of the OHCA may use and disclose protected health information across
the arrangement, as they would within their individual operations including as
necessary to carry out treatment, payment and health care operations.
However, we reserve the right to change the terms of this notice and our
privacy policies at any time. Any changes will apply to the health information
we already have. Before we make an important change to our policies, we will
promptly change this notice and post a new notice. You can also request a copy
of this notice from the contact person listed in Section VI below at any time
and can view a copy of the notice on our Web site at
III. Your Rights Under the Federal Privacy Standard
Although your health record is the physical property of the healthcare
provider who completed it, you have certain rights with regard to the
information contained therein. You have the right to:
A. Request a restriction on uses and disclosures of your health information.
You have the right to ask that we limit how we use and disclose your health
information. We will consider your request but are not legally required to
accept it. If we accept your request, we will put any limits in writing and
abide by them except in emergency situations. You may not limit the uses and
disclosures that we are legally required or allowed to make. In those cases, you
do not have a right to request restriction.
B. The Right to Choose How We Send Health Information to You. You may also
ask us to communicate with you by alternative means and, if the method of
communication is reasonable, we must grant the alternative communication
request. You have the right to ask that we send information to you to an
alternate address (for example, sending information to your work address rather
than your home address) or by alternate means (for example, e-mail instead of
regular mail). We must agree to your request so long as we can easily provide it
in the format you requested.
C. Obtain a copy of this notice of privacy practices. Although we have posted
a copy in prominent locations throughout the facility and on our Web site, you
have a right to a hard copy upon request. You have a right to get a copy of this
notice by e-mail. Even if you have agreed to receive notice via e-mail, you also
have the right to request a paper copy of this notice.
D. Inspect and copy your health information upon request. In most cases, you
have the right to look at or get copies of your health information that we have,
but you must make the request in writing. If we do not have your health
information, but we know who does, we will tell you how to get it. We will
respond to you within 30 days after receiving your written request. In certain
situations, such as if access would cause harm, we can deny access. If we do
deny the request, we will tell you, in writing, our reasons for the denial and
explain your rights to have the denial reviewed. You do not have a right of
access to the following:
1. Information compiled in reasonable anticipation of or for use in civil,
criminal, or administrative actions or proceedings.
2. Protected health information (PHI) that is subject to the Clinical
Laboratory Improvement Amendments of 1988 (CLIA), 42 USC 263a, to the extent
that the provision of access to the individual would be prohibited by law.
Information was obtained from someone other than a healthcare provider under
a promise of confidentiality and the access requested would be reasonably likely
to reveal the source of the information.
In other situations, we may deny you access but, if we do, we must provide
you with a review of the decision denying access. These "reviewable" grounds for
1. Licensed healthcare professional has determined, in the exercise of
professional judgment, that the access is reasonably likely to endanger the life
or physical safety of yourself or another person.
2. Health information makes reference to another person (other than a
healthcare provider) and a licensed healthcare provider has determined, in the
exercise of professional judgment, that the access is reasonably likely to cause
substantial harm to such other person.
3. The request is made by your personal representative and a licensed
healthcare professional has determined, in the exercise of professional
judgment, that providing access to such personal representative is reasonably
likely to cause substantial harm to you or another person.
4. For these reviewable grounds, another licensed professional must review
the decision of the provider denying access within 60 days. If we deny you
access, we will explain why and what your rights are, including how to seek
If we grant access, we will tell you what, if anything, you have to do to get
access. We reserve the right to charge a reasonable, cost-based fee for making
E. Request amendment/correction of your health information. If you believe
that there is a mistake in your health information or that a piece of important
information is missing, you have a right to request that we correct the existing
information or add the missing information. You must provide the request and
your reason for the request in writing. We will respond within 60 days of
receiving your request. We do not have to grant the request if:
1. We did not create the record. If, as in the case of a consultation report
from another provider, we did not create the record, we cannot know whether it
is accurate or not. Thus, in such cases, you must seek amendment/correction from
the party creating the record. If they amend or correct the record, we will put
the corrected record in our records.
2. The records are not available to you as discussed immediately above.
3. The record is accurate and complete.
If we deny your request for amendment/correction, we will notify you why, how
you can attach a statement of disagreement to your records (which we may rebut),
and how you can complain. If we grant the request, we will make the correction
and distribute the correction to those who need it and those you identify to us
that you want to receive the corrected information.
F. Obtain an accounting of "non-routine" uses and disclosures- those other
than for treatment, payment and healthcare operations. You have the right to get
a list of instances in which we have disclosed your health information.
We do not need to provide an accounting for disclosures of protected health
- to you
- to the facility directory or to persons involved in
your care or for other notification purposes
- for national security or intelligence purposes
- to correctional institutions or law enforcement
- that occurred before April 14, 2003.
We must provide the accounting within 60 days. The list we will give you will
include disclosures made in the last six years unless you request a shorter
time. The accounting must include:
- date of each disclosure
- name and address of the organization or person who
received the protected health information
- a brief description of the information disclosed
- a brief statement of the purpose of the disclosure that reasonably informs
you of the basis for the disclosure or, in lieu of such statement, a copy of
your written authorization, or a copy of the written request for
The first accounting in any 12-month period is free. Thereafter, we reserve
the right to charge a reasonable, cost-based fee.
G. Revoke your consent or authorization to use or disclose health information
except to the extent that we have already taken action in reliance on the
consent or authorization.
IV. Our Responsibilities Under the Federal Privacy Standard
In addition to providing you your rights, as detailed above, the federal
privacy standard requires us to:
A. Maintain the privacy for your health information, including implementing
reasonable and appropriate physical, administrative, and technical safeguards to
protect the information.
B. Provide you with this notice as to our legal duties and privacy practices
with respect to individually identifiable health information we collect and
maintain about you.
C. Abide by the terms of this notice.
D. Train our personnel concerning privacy and confidentiality.
E. Implement a sanction policy to discipline those who breach
privacy/confidentiality or our policies with regard thereto.
F. Mitigate (lessen the harm of) any breach of privacy/confidentiality.
We will not use or disclose your health information without your consent or
authorization, except as described in this notice or otherwise required by
V. How We May Use and Disclose Your Protected Health Information
We use and disclose health information for many different reasons. For some
of these uses or disclosures, we need your prior consent or specific
authorization. Below, we describe the different categories of our uses and
disclosures and give you some examples of each category.
A. Uses and disclosures relating to treatment, payment or healthcare
operations. We may use and disclose your health information for the following
1. For Treatment. We may disclose your health information
to physicians, nurses, healthcare students, and other healthcare personnel who provide
you with healthcare services or are involved in your care. For example, an
anesthesiologist, a psychiatrist, psychologist, chaplain, clinical social
worker, other therapist or counselor, nurse, or other member of your healthcare
team will record information in your record to diagnose your condition and
determine the best course of treatment for you. The primary caregiver will give
treatment orders and document what he or she expects other members of the
healthcare team to do to treat you. Those other members will then document the
actions they took and their observations. In that way, the primary caregiver
will know how you are responding to treatment. We will also provide your
physician, other healthcare professionals, or a subsequent healthcare provider
with copies of your records to assist them in treating you once we are no longer
2. To Obtain Payment for Treatment. We may use and disclose your
health information in order to bill and collect payment for treatment and
services provided to you. For example, we may provide portions of your health
information to our Patient Accounts Department and your health plan/insurer to get paid
for the healthcare services we provided to you. The information provided may
include information that identifies you, your diagnosis, procedures, treatments
received, and supplies used. We may also provide your health information to our
business associates, such as billing companies, claims processing companies, and
others that process our health care claims. We may disclose your health
information to a business associate so that they can perform the functions(s) we
have contracted with them to do. To protect your health information, however, we
require the business associate to appropriately safeguard your information.
3. For Health Care Operations. We may disclose your
health information in order to operate this hospital. For example, we may use
your health information in order to evaluate the quality of healthcare services that you received
or to evaluate the performance of the healthcare professionals who provided
healthcare services to you. We will use this information in an effort to continually
improve the quality and effectiveness of the healthcare and services we provide.
We may also provide your health information to our accountants, attorneys,
consultants, and others in order to make sure we are complying with the laws
that affect us.
B. Certain Uses and Disclosures Do Not Require Your Consent. We may use and
disclose your health information without your consent or authorization for the
1. When a disclosure is required by federal, state or local law, judicial, or
administrative proceedings, or law enforcement. For example, we make disclosures
when a law requires that we report information to government agencies or law
enforcement personnel about victims of abuse, neglect, or domestic violence;
when dealing with gunshot or other wounds; or when ordered in a judicial or
administrative proceeding. We may disclose health information for purposes as
required by law or in response to a valid subpoena.
2. For public health activities. For example, we report information about
births, deaths, and various diseases, to government officials in charge of
collecting that information, and we provide coroners and medical examiners
necessary information relating to an individual’s death. As required by law, we
may disclose your health information to public health or legal authorities
charged with preventing or controlling disease, injury or disability. We may
disclose health information to funeral directors consistent with applicable law
to enable them to carry out their duties.
3. For health oversight activities. For example, we will provide
information to assist the government when it conducts an investigation or inspection of
a healthcare provider or organization.
4. For purposes of organ donation. We may notify organ procurement
organizations to assist them in organ, eye, or tissue donation and
5. For research purposes. We may disclose information to researchers when
their research has been approved by an institutional review board that has
reviewed the research proposal and established protocols to ensure the privacy
of your health information.
6. To avoid harm. In order to avoid a serious threat to the health or safety
of a person or the public, we may provide health information to law enforcement
personnel or persons able to prevent or lessen such harm.
7. For specific government functions. We may disclose health information of
military personnel and veterans in certain situations. And we may disclose
health information for national security purposes, such as protecting the
president of the United States or conducting intelligence operations.
8. For workers’ compensation purposes. We may disclose health information to
the extent authorized by and to the extent necessary to comply with laws
relating to workers’ compensation or other similar programs established by
9. Appointment reminders and health-related benefits or services. We may
use health information to provide appointment reminders or give you
information about treatment alternatives, or other healthcare services or benefits we
offer. We may use your health information to provide instructions prior to
10. Fund-raising activities. We may use health information to raise funds
for our organization. The money raised through these activities is used to
expand and support the healthcare services and educational programs we provide to the
community. If you do not wish to be contacted as part of our fund-raising
efforts, please contact the person listed in Section VI below.
11. Food and Drug Administration (FDA). We may disclose to the FDA health
information relative to adverse effects/events with respect to food, drugs,
supplements, product or product defects, or post marketing surveillance
information to enable product recalls, repairs, or replacements.
12. Correctional institution. Should you be an inmate of a correctional
institution, we may disclose to the institution or agents thereof health
information necessary for your health and the health and safety of other
13. The Federal Department of Health and Human Services (HHS). Under the
privacy standards, we must disclose your health information to HHS as necessary
for them to determine our compliance with those standards.
C. Two Uses and Disclosures Require You to Have the Opportunity to Object.
1. Patient Directories. We may include your name, location in facility,
general condition, and religious affiliation, in our patient directory for use
by clergy and visitors who ask for you by name, unless you object in whole or in
part. The opportunity to consent may be obtained retroactively in emergency
2. Disclosures to family, friends or others. We may provide your health
information to a family member, friend, or other person that is involved in your
care or the payment for your health care, unless you object in whole or in part.
Health professionals using their best judgment may disclose to a family member,
other relative, close personal friend health information relevant to that
person’s involvement in your care or payment related to your
VI. How to Get More Information
If you have questions and/or would like additional information, you may
contact the Privacy Officer at 269-983-8195.
VII. How to Complain About Our Privacy Practices
If you think that we may have violated your privacy rights, or you disagree
with a decision we made about access to your health information, you may contact
the Lakeland privacy officer at 269-983-8195. The privacy officer will follow up
on all complaints and respond in writing within 60 days of the complaint.
You also may send a written complaint to the secretary of the Department of
Health and Human Services.
The U.S. Department of Health and Human Services
200 Independence Avenue,
Washington D.C., 20201
We will take no retaliatory action against you if you file a complaint about
our privacy practices.
VIII. Effective Date of This Notice
This notice went into effect on April 1, 2003