USA Privacy Notice

This Privacy Notice covers an Organized Health Care Arrangement (OHCA) known as USA Health, made up of the entities listed on the last page of this Notice.

The effective date of this notice is October 1, 2023.

Our Pledge Regarding Health Information:

We understand that health information about you is personal and are committed to protecting your health information. Health information is your health history, symptoms, test results, diagnosis, treatment, and claims and payment history. We create a record of the care and services you receive within USA Health. The record is needed to provide you with quality care and to comply with certain legal requirements. This notice applies to all records pertaining to your health care in possession by USA Health.

This notice will tell you about the ways in which we may use and disclose your health information. It also describes your rights and certain obligations we have regarding the use and disclosure of health information. If you have any questions about this notice or how health information is used or disclosed, please call the USA Office of HIPAA Compliance at (251) 445-9192.

We are required by law to:

• Make sure that your health information is protected;
• Make you aware of our legal duties and privacy practices with respect to your health information;
• Notify you if there is a breach of your identifiable medical information; and
• Follow the terms of the USA Health Privacy Notice.

How We May Use And Disclose Your Health Information:

The following categories describe different ways that we may use and disclose your health information. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of these categories.

1. General Uses and Disclosures. Under the Privacy Rules, we are permitted to use and disclose your health information for the following purposes, without obtaining your permission or authorization:
   1. Treatment: We can use and disclose your health information to provide medical treatment or services. For example, we may disclose your health information to your primary care provider, consulting providers, and to other health care personnel who have a need for such information for your care and treatment.
   2. Payment: We can use and disclose your health information for the purposes of determining coverage, billing, and payment. For example, a bill sent to your insurance company may include information that identifies you, your diagnoses, procedures, and supplies used in your treatment. We may also use and disclose your health information about a treatment/procedure you are going to receive to obtain prior approval/authorization or to determine whether your plan will cover the treatment/procedure. We may use and disclose your health information to a Medicaid eligibility database as applicable.
   3. Healthcare Operations: We can use and disclose your health information for our health care operations. These include, but are not limited to: quality assurance, auditing, licensing, credentialing and for educational purposes. For example, we can use your health information to internally assess our quality of care provided to patients. We may also use and disclose your health information to assess your satisfaction with our services.
   4. Uses and Disclosures Related to OHCA: The health care providers participating in the OHCA and listed in this Notice will share your health information with each other, as necessary, to carry out treatment, payment and health care operations related to the OHCA.
   5. Alabama One Health Record System: USA Health participates in the State of Alabama’s Health Information Exchange, known as Alabama One Health Record, that allows us to exchange electronic health information with hospitals, physicians, and other network participants who share information in the system in the event we need to see or receive the information to treat you. Our participation helps to improve the quality of care you receive. You may choose not to have your electronic health information included in the system by submitting a written request, on the required form, to the Patient Access office located at any USA Health hospital site or by contacting the USA Office of HIPAA Compliance.
      
   6. Health Information Exchange/Regional Health Information Organization: Federal and state laws permit us to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share your health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of your health records; decreasing the time needed to access your information; aggregating and comparing your information for quality improvement purposes; and such other purposes as may be permitted by law.
   7. As Required By Law: We may use and disclose your health information when required to do so by federal, state, and/or local law, including, but not limited to: reporting abuse; neglect and domestic violence; in response to judicial and administrative proceedings; in responding to a law enforcement request for information; in order to alert law enforcement to criminal conduct on our premises or of a death that may be the result of criminal conduct; for review by legal counsel; or the US Department of Health and Human Service and the Office for Civil Rights.
      
   8. Public Health Activities: We may disclose your health information to public health or legal authorities charged with protecting the health and well-being of the general public. This information may include but is not limited to: reporting communicable diseases and vital statistics; product recalls and adverse events; or notifying person(s) who may have been exposed to a disease or are at risk of contracting or spreading a disease or condition.
   9. Food and Drug Administration (FDA): We may disclose to the FDA and to manufacturers health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs, and/or replacements.
   10. Abuse and Neglect: We may disclose your health information to a federal, state, or local government authority, if we have a reasonable belief of abuse, neglect, or domestic violence.
   11. Health Oversight Activities: We may disclose your health 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.
   12. Judicial and Administrative Proceedings: We may disclose your health information in judicial and administrative proceedings, as well as in response to an order of a court, administrative tribunal, or in response to a subpoena, summons, warrant, discovery request, or similar legal request.
   13. Law Enforcement Purposes: We may disclose your health information to law enforcement officials, when required to do so by law.
   14. Coroners, Medical Examiners and Funeral Directors: We may release your health 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 your health information to funeral directors, as necessary, to carry out their duties.
   15. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your health information 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 that of others, or for the safety and security of the correctional institution.
   16. Threat to Health or Safety: We may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
   17. Specialized Government Functions/Military and Veterans: If you are a member of the U.S. Armed Forces, we may release your health information as required by military command authorities. We may also disclose your health information to authorized federal officials for national security reasons and the Department of State for medical suitability determinations. 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.
   18. Workers’ Compensation: We can release your health information to your employer to the extent necessary to comply with Alabama law relating to workers’ compensation or other similar programs.
       
   19. Appointment Reminders/Treatment Alternatives: We may use and disclose health information to contact you as a reminder of an appointment for treatment or medical care. We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you and to provide case management or care coordination.
   20. Marketing: We may use or disclose your health information to make a marketing communication to you that occurs in a face-to-face encounter with us or which concerns a promotional gift of nominal value provided by us. We do not sell your health information to any third party for their marketing activities unless you sign an authorization allowing us to do this.
   21. Fundraising: We may use or disclose your health information to make a fundraising communication to you, for the purpose of raising funds for our own benefit. Included in such fundraising communications will be instructions describing how you may ask not to receive future communications. We will ensure that if you opt out of such communications you are not sent future fundraising communications.
   22. Business Associates: We may disclose your health information to business associates who provide services to us. Our business associates are required to protect the confidentiality of your health information.
   23. Research: Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of 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 where certain safeguards are in place to ensure the privacy and protection of your health information.
   24. Organ and Tissue Donation: We may release your health information to organizations that handle organ procurement or organ/eye/tissue transplantation, or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
       
   25. Hospital Directory: Unless you object, we may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition and your religious affiliation. 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, such as priest or minister, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. Except in emergency situations, you will be notified in advance and have the opportunity to verbally agree or object to this use and disclosure of your health information.
   26. Other Uses and Disclosures: In addition to the reasons outlined above, we may use and disclose your health information for other purposes permitted by the Privacy Rules. For example, if reasonable precautions are taken to minimize the chance that others who may be nearby accidentally overhear your health information, the following practices are permissible under the Privacy Rules, because they are considered incidental disclosures: health care staff may orally coordinate services at hospital nursing stations; nurses or other health care professionals may discuss a patient’s condition over the phone with the patient, a provider, or a family member; a health care professional may discuss lab test results with a patient or other provider in a joint treatment area; a physician may discuss a patient’s condition or treatment regimen in the patient’s semi-private room; health care professionals may discuss a patient’s condition during training rounds, other training settings and for training purposes; a pharmacist may discuss a prescription with a patient over the pharmacy counter, or with a physician or the patient over the phone. Uses and disclosures not described in this Notice will be made only with your written authorization.
2. Uses and Disclosures, Which Require You the Opportunity to Verbally Agree or Object: Under the Privacy Rules, we are permitted to use and disclose your health information: (i) for the creation of facility directories, (ii) to disaster relief agencies, and (iii) to family members, close personal friends or any other person identified by you, if the information is directly relevant to that person’s involvement in your care or treatment. Except in emergency situations, you will be notified in advance and have the opportunity to verbally agree or object to this use and disclosure of your health information.
3. Uses and Disclosures, Which Require Written Authorization: We can use your health information for purposes other than the categories listed above with your written authorization. For example, disclosures that constitute a sale of your protected health information will only be done with your written authorization. In addition, in order to disclose your health information to a company for marketing purposes, we must obtain your authorization. Further disclosures of psychotherapy notes require your written authorization. Under the Privacy Rules, you may revoke your authorization at any time. The revocation of your authorization will be effective immediately, except to the extent that: we have relied upon it previously for the use and disclosure of your health information; the authorization was obtained as a condition of obtaining insurance coverage where other law provides the insurer with the right to contest a claim under the policy or the policy itself; or your health information was obtained as a part of a research study and is necessary to maintain the integrity of the study. Other uses and disclosures not described in this Privacy Notice will only be made with your written authorization.

Your Rights Regarding Health Information About You:

Although all records concerning your care and treatment maintained within the USA Health system are the property of USA Health, you have the following rights regarding health information we maintain about you:

• Right to Inspect and Copy: You have the right to inspect and copy your own health information contained in a designated record set, maintained by or for us. A “designated record set” contains medical and billing records and any other records that we use for making decisions about you. However, we are not required to provide you access to all the health information we maintain. For example, this right of access does not extend to psychotherapy notes, or information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative proceeding. Where permitted by the Privacy Rules, you may request that certain denials to inspect and copy your health information be reviewed. Instead of copies, we can provide you with a summary of your health information, if you agreed to the form and of such summary. You may also request that we transmit a copy of such health information to a designated third-party, provided the designation is clear, specific, in writing, and signed by you. Your request to Inspect and Copy will be responded to within the time period set forth in the HIPAA regulations.
• Right to Access Electronic Health Record: If we maintain your health information in an electronic health record, we are required to make that record available to you (or another person or entity designated by you) in an electronic format upon your written request.
• Right to Request an Amendment of Your Health Information: If you feel that the health 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 of your health information as long as the information is kept by or for USA Health. We may deny your request if we determine you have asked us to amend information that: was not created by us, unless the person or entity that created the information is no longer available; is not health information maintained by or for us; is health information that you are not permitted to inspect or copy; or we determine the health information is accurate and complete. We will provide you with a written explanation of the reasons for the denial, an opportunity to submit a statement of disagreement, and a description of how you may file a complaint.
• Right to an Accounting of Disclosures of Your Health Information: You have the right to receive an accounting of disclosures of your health information made by us within six (6) years prior to the date of your request. This is a list of certain disclosures we made of health information about you. The first list you request within a twelve (12) month period is free. For additional lists, we may charge you the cost of providing the list.
• Right to Request Restrictions on the Use and Disclosure of Your Health Information: You have the right to request restrictions on the use and disclosure of your health information for treatment, payment and health care operations, as well as disclosures to persons involved in your care or the payment for your care, like a family member or close friend. We are not required to agree to your request unless all of the following conditions apply: you request that your health information not be disclosed to your health plan; the purpose of the disclosure is not related to treatment; and the health care services to which the health information applies have been paid for out-of-pocket in full. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
• Right to Request That Health Information Pertaining to Services Paid Out of Pocket Not Be Sent to Insurance or Other Health Plans: In some instances, you may choose to pay for a healthcare service out of pocket, rather than submit a claim to your insurance company. You have the right to request that we not submit your health information to a health plan or your insurance company, if you, or someone on your behalf, pay for the treatment or service out of pocket in full. To request this restriction, you must make your request in writing on the required form prior to the treatment or service. In your request, you must tell us (1) what information you want to restrict (2) and to what health plan the restriction applies.
• Right to Alternative Communications: You have the right to receive confidential communications of your health information by a different means or at a different location than currently provided. For example, you may request that we only contact you at home or by mail. We will accommodate all reasonable requests.
• Right to Receive Notification of a Breach of Your Unsecured Health Information: You have a right to and will be notified if there has been a breach of your unsecured health information.
• Right to a Paper Copy of this Privacy Notice: You have the right to a paper copy of this notice, even if you have agreed to receive this notice electronically. You may also obtain a copy of this notice at our website, www.usahealthsystem.com/privacy-notice.
  

If you want to exercise any of these rights, other than “Right to Inspect and Copy” or “Right to Access Electronic Health Record” please contact the USA Office of HIPAA Compliance at (251) 445-9192.

To exercise the “Right to Inspect and Copy” or “Right to Access Electronic Health Record” please contact the facility as listed below. Your request will only apply to the facility you contact.

USA Health University Hospital - (251) 471-7350
USA Health Children’s & Women’s Hospital – (251) 415-1642
USA Health Providence Hospital – (251) 266-2759
USA Hospitals Business Office – (251) 434-3505
USA Health Physicians Group – (251) 434-3711
USA Health Care Authority (HCA) - (251) 378-6232
USA Health Mitchell Cancer Institute - (251) 445-9675
USA Pat Capps Covey Allied Health Professions - (251) 445-9378
USA Health Providence Clinics – (251) 300-8053

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 health information we already have about you as well as any information we receive in the future. We will post a copy of the notice currently in effect in all our locations and on the web at www.usahealthsystem.com/privacy-notice. In addition, the notices will be available at our locations for individuals to take with them.

Contact Information and How to Report a Privacy Rights Violation

If you believe your privacy rights have been violated or that we have violated our own privacy practice, you may file a complaint with us. You may also file a complaint with the Secretary of the U. S. Department of Health and Human Services. There will be no retaliation for filing a complaint.

To file a complaint with USA Health, contact the USA Office of HIPAA Compliance at (251) 445-9192.

USA Health Organized Health Care Arrangement and Locations

For purposes of compliance with the HIPAA regulations, USA Health has been designated as an Organized Health Care Arrangement (OHCA), which includes: USA Health University Hospital, USA Health Children’s & Women’s Hospital, USA Health Providence Hospital, USA Health Physicians Group, University of South Alabama Health Care Authority and the USA Pat Capps Covey Allied Health Professions, the University of South Alabama College of Nursing, the University of South Alabama College of Medicine and the University of South Alabama Psychology Clinic. These entities participate in a clinically and operationally integrated care setting in which it is necessary to share PHI for joint management and operations.

As part of our OHCA, the following entities provide services at the following locations and are covered by this Privacy Notice. In addition, there may be other health care providers who provide services at these locations that are not employees of USA but are part of the USA Health OHCA and are covered by this Privacy Notice. In addition, there may be other locations that operate under the USA Health OHCA that are not listed below.

University of South Alabama Hospitals:
USA Health University Hospital
USA Health Children’s & Women’s Hospital
USA Health Providence Hospital

University of South Alabama Mitchell Cancer Institute:
USA Health Mitchell Cancer Institute - Mobile/Fairhope/Springhill Clinics

University of South Alabama Physicians Group:
USA Health University Hospital Campus Mastin Professional Building
USA Health University Hospital Heart Station
USA Health University Hospital Department of Emergency Medicine
USA Health University Hospital Freestanding Emergency Department
USA Health Stanton Road Clinic
USA Health Strada Patient Care Center
USA Health University Commons
USA Health Physicians Group Eastern Shore Surgical Specialists
USA Health Baldwin County Surgery Center
USA Health Mapp Family Campus
USA Health Eastern Shore OB/GYN & Pediatrics
USA Health Psychology Clinic*
USA Health Semmes Pediatrics
USA Health Family Practice in partnership with Accordia Health
USA Health Baldwin Family Medicine

University of South Alabama Health Care Authority:
USA Health Citronelle Primary Care
USA Health Coastal OB/GYN
USA Health Cottage Hill Primary Care
USA Health Family Practice Associates
USA Health Hillcrest Primary Care
USA Health Mobile Diagnostic Center
USA Health Mobile Diagnostic Center University Commons
USA Health University OB-GYN
USA Health University Urology
USA Health Urogynecology of Southern Alabama
USA Health Endocrine & Diabetes
USA Health Dermatology
USA Health Pain Management
USA Health Semmes Primary Care
USA Health Schillinger Primary Care
USA Health Industrial Medicine
USA Health Midtown
USA Health Providence Airport Primary Care
USA Health Providence Radiology Oncology
USA Health Providence Endocrinology
USA Health Providence Gastroenterology
USA Health Providence Podiatry
USA Health Providence Surgical Services
USA Health Providence West Mobile Medical Group
USA Health Providence Bariatrics
USA Health Providence Pharmacy
USA Health Snow Road Primary Care
USA Health South Coast Family Practice
USA Health Tillmans Corner Primary Care
Mobile Heart USA Health Cardiology
Pediatric Associates of Mobile

USA Pat Capps Covey Allied Health Professions:
Physical Therapy Clinic
Radiologic Sciences Clinic
Speech Pathology and Audiology Clinic

Satellite Clinics:
Bayview Professional Associates (Psychiatry)
Fresenius Kidney Care
USA Health Surgical Specialists
USA Health Surgical Navigation Center
USA Health Pediatric Resident Clinic
USA Health OB-GYN Resident Clinic
USA Health Pediatric Orthopedic Therapy Clinic
USA Orthopedic Rehabilitation Clinic at USA Tech Park

* USA Psychology Clinic is part of the USA Health OHCA but is not covered by this Privacy Notice.