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UPMC Chautauqua Notice of Privacy Practices

Click here to obtain a copy of this notice. (PDF, 26Kb)

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.

Effective Date: April 14, 2003

Who Will Follow This Notice?
All employees, volunteers, students, business associates of UPMC Chautauqua, including JMHC and all satellite health centers, as well as medical staff members while providing treatment at any UPMC Chautauqua site.

Our Pledge Regarding Medical Information

We are committed to protecting medical information about you. We create a record of the care and services you receive at UPMC Chautauqua. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records maintained at UPMC Chautauqua, whether made by hospital personnel or your personal doctor. 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. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:



How We May Use And Disclose Medical Information About You

The following categories describe different ways that we use and disclose medical information. Not every use or disclosure in a category will be listed. All of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at our facilities. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of UPMC Chautauqua may share medical information such as prescriptions, lab work and x-rays to better coordinate your care.

We may disclose medical information about you to people outside UPMC Chautauqua who may be involved in your medical care after you leave the hospital such as family members, clergy or others we use to provide services that are part of your care. We will also provide your physician or subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you have been discharged from our services.

For Payment
We may use and disclose medical information about you so that we can receive payment. For example, a bill may be sent to you or a third party payer. This information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover this treatment.

For Health Care Operations
We may use and disclose medical information about you for organizational operations. These uses and disclosures are necessary to run our facilities and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. You may be contacted by an organization to assess your satisfaction with our services.

We may also combine medical information about many UPMC Chautauqua patients to determine community health needs.

We may disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may combine the medical information we have with medical information from other sources to compare how we are doing and see where we can make improvements in the care and services we offer.

We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

For Business Associates
There are some services provided for our organization through contracts with business associates. Examples include: physician services in the Emergency Department; Radiology and for certain laboratory tests. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we have asked them to do and bill you or your third party payer for services rendered.

To protect your health information we require the business associate to appropriately safeguard your information.

For Appointment Reminders
We may use and disclose medical information to contact you to schedule or pre-register you for certain services or to give you a reminder that you have an appointment for treatment or medical care at a UPMC Chautauqua site.

For Treatment Alternatives
We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

For 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.

For Fundraising Activities
We may use information about you to contact you in an effort to raise money for UPMC Chautauqua and its operations. We may disclose information to a foundation related to UPMC Chautauqua so that the foundation may contact you. We only release contact information such as your name, address and phone number and the dates you received treatment or services at UPMC Chautauqua.

For The Hospital Directory
We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This is so your family, friends and clergy can visit you in the hospital.

This information may include your name, location in the hospital, religious affiliation and in some instances your condition. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy even if they don't ask for you by name.

For Notification
We may use or disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care. We may disclose your location and general condition.

For Communication With Family
Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

For Research
Under certain circumstances, we may use and disclose medical information about you for research purposes. 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 are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will be approved by the Institutional Review Board. We may obtain your authorization as well.

As Required By Law
We will disclose medical information about you when required to do so by federal, state or local law.

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. Any disclosure would only be to someone able to help prevent the threat. In addition, we may disclose 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.

Special Situations

Organ and Tissue Donation
If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation. This may include an organ donation bank as necessary to facilitate donation and transplantation, as mandated by law.

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.

Worker's Compensation
We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks
We may disclose medical information about you for public health activities as mandated by law.

These activities generally include the following:


Health Oversight Activities
We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities may include 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
If you are involved in a lawsuit or a dispute, 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 by someone else involved in the dispute. This will happen only if we receive documentation that the requestor of the information has made reasonable effort to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement
We may release medical information to a law enforcement official:


Coroners, Medical Examiners, Funeral Directors
We may release medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary 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 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 to conduct special investigations.

Disaster Relief
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.

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 for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution.

Your Rights Regarding Medical Information

You have the following rights regarding medical information we maintain about you:

Your Right to Inspect and Copy
You have the right to inspect and obtain a copy of your 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.

To inspect and obtain copies of this medical information, you must submit your request in writing to Health Information Management. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or for other supplies associated with your request.

We may deny your request to inspect and obtain copies in certain very limited circumstances. If you are denied access to medical information, your rights under New York State law are explained in a brochure titled, You and Your Medical Records. This brochure may be obtained from Health Information Management.

Your Right 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 UPMC Chautauqua. To request an amendment, your request must be submitted in writing by completing a form which is available from Health Information Management. This form includes a section to record your reason for requesting the amendment.

We may deny your request for an amendment if it is not submitted on the approved form or if you ask us to amend information that:


Your Right to an Accounting of Disclosures
You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you, excluding those for which you signed an authorization. To request this accounting of disclosures, you must submit the appropriate form to Health Information Management.

Your request must state a time period, which may not be for disclosures more than six years prior to your request 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.

Your 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. 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 complete a Request to Restrict Protected Health Information.

Your Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters by alternative means or at alternative locations. To request confidential communications, you must make your request by completing a Request to Alternate Communications. We will not ask you the reason for your request. We will accommodate all reasonable requests.

Your 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 of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice in PDF format (26Kb) by clicking here. To obtain a paper copy of this notice, you may contact the patient representative.

Changes To This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed 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 in the facility. The notice will contain on the first page, in the top right-hand corner, the effective date. Each time you register as an inpatient or outpatient, we will have a copy of the most current notice available to you upon request.


If you believe your privacy rights have been violated, you may file a complaint with UPMC Chautauqua or with the Secretary of the Department of Health and Human Services. To file a complaint, contact the patient representative at 716-664-8271. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses Of Medical Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. If you have any questions about this notice, please contact our Patient Representative at  716-664-8271.