Privacy Notice Southern Coos Health District
Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions.
Your Rights
When it comes to your health information, you have certain rights.
and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually
within 30 days of your request. We may charge a reasonable, cost-based fee.
• You can ask us to correct health information about you that you think is
incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within
60 days
• You can ask us to contact you in a specific way (for example, home or office
phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests
• 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.
• You can ask for a list (accounting) of the times we’ve shared your health information
for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and
health care operations, and certain other disclosures (such as any you asked us to
make). We’ll provide one accounting a year for free but will charge a reasonable,
cost-based fee if you ask for another one within 12 months.
• You can ask for a paper copy of this notice at any time, even if you have agreed to
receive the notice electronically. We will provide you with a paper copy promptly.
• If you have given someone medical power of attorney or if someone is your legal
guardian, that person can exercise your rights and make choices about your health
information.
• We will make sure the person has this authority and can act for you before we take
any action.
• You can complain if you feel we have violated your rights by contacting us
using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human
Services Office for Civil Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
https://www.hhs.gov/hipaa/index.html
• We will not retaliate against you for filing a complaint.
• If you wish to inspect, amend, or copy your medical information, you must submit
your request in writing to Health Information Management Department, 900 11th
St SE, Bandon, OR 97411. We will have 30 days to respond to your request for
information that we maintain at our facility.
Your Choices
If you have a clear preference for how we share your information in the situations described
below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead
and share your information if we believe it is in your best interest. We may also share your
information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy note
• We may contact you for fundraising efforts, but you can tell us not to contact you
again.
Our Uses and Disclosures
We typically use or share your health information in the following ways.
• We can use your health information and share it with other professionals who are
treating you.
• Example: A doctor treating you for an injury asks another doctor about your
overall health condition.
• We can use and share your health information to run our practice, improve your
care, and contact you when necessary.
• Example: We use health information about you to manage your treatment and
services.
• We can use and share your health information to bill and get payment from health
plans or other entities.
• Example: We give information about you to your health insurance plan so it will
pay for your services
We are allowed or required to share your information in other ways – usually in ways that contribute
to the public good, such as public health and research. We have to meet many conditions in the law
before we can share your information for these purposes.
For more information see:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticep
p.html
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
• We can use or share your information for health research.
• We will share information about you if state or federal laws require it, including
with the Department of Health and Human Services if it wants to see that we’re
complying with federal privacy law.
• We can share health information about you with organ procurement organizations.
• We can share health information with a coroner, medical examiner, or funeral
director when an individual dies.
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential
protective services
We can share health information about you in response to a court or administrative order, or
in response to a subpoena.
Our Responsibilities
• We are required by law to maintain the privacy and security of your
protected health information.
• We will let you know promptly if a breach occurs that may have compromised the
privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give
you a copy of it.
• We will not use or share your information other than as described here unless you
tell us we can in writing. If you tell us we can, you may change your mind at any
time. Let us know in writing if you change your mind.
For more information see:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
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.
Southern Coos Hospital & Health Center – A Critical Access Hospital
And Southern Coos Outpatient Multi-Specialty Clinic
If you want more information about our privacy practices or have questions or concerns, please
contact us using the information listed at the end of this notice.
If you believe your privacy rights have been violated, you can file a complaint with the Privacy
Officer, Southern Coos Hospital and Health Center, 900 Eleventh Street SE, Bandon, Oregon
97411, in writing, in person, or by calling the Southern Coos Hospital and Health Center Risk and
Compliance Officer:
Amanda Bemetz
Director of Quality, Risk & Compliance
Southern Coos Hospital and Health Center
Email: abemetz@southerncoos.org
541-347-0512 (office)
541-347-2426, ext. 190 (front desk)
Address: 900 Eleventh Street SE, Bandon, Oregon 97411
Telephone: (541) 347-2426
website: https://www.southerncoos.org
You may also file a complaint with the Secretary of the U.S. Department of Health and Human
Services in Washington D.C. in writing within 180 days of a violation of your rights. There will be
no retaliation for filing a complaint.
Inclusive Patient Care and Communication
SCHHC complies with applicable state and federal civil rights laws and does not discriminate,
exclude people or treat them differently on the basis of:
• Race
• Color
• National origin
• Age
• Disability; or
• Sex.
SCHHC provides free auxiliary aids and services to people with disabilities to communicate
effectively with us, such as:
• Written information in other formats (large print, audio, accessible electronic
formats and other formats)
SCHHC also provides free language services to people whose primary language is not English,
such as:
• Information written in other languages
If you need these services, contact your care provider’s office. They will make the language services
arrangements for you.
If you believe that Southern Coos Hospital & Health has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age, disability or sex, you
can file a grievance in writing with the Risk and Quality Compliance Officer:
Amanda Bemetz
Director of Quality, Risk & Compliance
Southern Coos Hospital and Health Center
Email: abemetz@southerncoos.org
541-347-0512 (office)
541-347-2426, ext. 190 (front desk)
Address: 900 Eleventh Street SE, Bandon, Oregon 97411
Telephone: (541) 347-2426
website: https://www.southerncoos.org
You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, the
Risk & Compliance Officer is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of
Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, D.C. 20201, 800-868-1019, 800-537-7697 (TDD). Complaint forms are availaable
at http://www.hhs.gov/ocr/office/file/index.html.
Language assistance services are available to you free of change upon request. Please let your
provider’s office staff know that you need language services for your visit.
Español (Spanish)
Si usted habla español, contamos con servicios de asistencia de idiomas, sin costo, disponibles para
usted. Si necesita estos servicios, comuníquese al consultorio de su proveedor de atención médica.
Ellos gustosamente coordinarán los servicios de idiomas para usted.
Tiếng Việt (Vietnamese)
Nếu bạn nói tiếng Việt, dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn dành cho bạn. Nếu bạn cần
những dịch vụ này, hãy liên lạc văn phòng của bác sĩ chăm sóc của bạn. Họ sẽ sẵn sàng thu xếp các
dịch vụ ngôn ngữ cho bạn.
中文(Chinese-Simplified)
如果您说中文，可为您提供免费的语言援助服 务。如果您需要这些服务，请联系您保健提
供 者的办公室。他们将乐意为您安排语言服务。
Русский (Russian)
Если вы говорите на русском языке, вам могут предоставить бесплатные услуги переводчика.
Если вам требуются такие услуги, обратитесь в офис своего поставщика медицинских услуг.
Сотрудники с радостью предоставят вам переводчика!
한국어 (Korean)
한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 이 서비스가
필요하시면 귀하의 의료 제공자 사무실에 연락하십시오. 귀하를 위해 기꺼이 언어
서비스를 준비해드릴 것입니다.
Українська (Ukrainian)
Якщо ви розмовляєте українською мовою, послуги мовної допомоги доступні для вас
безкоштовно. Якщо вам потрібні ці послуги, зв’яжіться з офісом вашого постачальника послуг.
Вони будуть раді надати вам послуги мовної допомоги.
日本語 (Japanese)
あなたの母語が日本語であれば、言語サポートサ ービスを無料にてご用意しています。
サービスをご 希望の場合には、あなたのケアプロバイダー事務 所までご連絡ください。
喜んで言語サポートサービ スの手配をいたします。
العربیة
(Arabic)
إذاكنتتتحدثالعربیة،فإنخدماتاملساعدةاللغویةمتاحةلكًا.إذاكنتتحتاجإىلھذهالخدمات،فاتصلمبكتب
مقدممجانالرعایةالخاصبك.سیكوناملوظفونھناكسعداءبإجراءالرتتیبات.املتعلقةبالخدماتاللغویةمنأجلك
Română (Romanian)
Dacă vorbiți română, puteți beneficia de asistență lingvistică gratuită. Dacă aveți nevoie de astfel de
servicii, luați legătura cu biroul furnizorului dvs. de servicii medicale. Reprezentanții acestuia vă vor
ajuta cu plăcere să beneficiați de asistență lingvistică.
មន-ែខ�រ (Mon-Khmer Cambodian)
្រ
បសិនេបើេ�កអ�កនិ�យ�� មន-ែខ�រ, ��ែខ�រ េ�ះេស�ជំនួយែផ�ក���នផ�ល់ជូ
នេ�កអ�កេ�យឥតគិតៃថ�។ ្រ បសិនេបើេ�កអ�ក ្រ ត�វ�រេស��ំងេនះ
សូមទំ�ក់ទំនងេ��ន់�រ �� ល័យអ�កផ�ល់�រែថ�ំរបស់េ�កអ�ក។ ពួកេគ
េពញចិត�ក��ង�រេរៀបចំេស�ែផ�ក��េផ្សងៗ ស្រ�ប់េ�កអ�ក។
Oroomiffa (Oromo)
Afaan Kuush (Oromoo) , dubbattu yoo ta’e, tajaajilliwwan deeggarsa afaanii, kaffaltii irraa bilisa ta’an,
isiniif ni jiraatu.Tajaalilawwan kanneen ni barbaaddu yoo ta’e , wajjira dhiyeessaa deeggarsa keessanii
qunnamaa. Isaan gammachuudhaan tajaajilawwan afaanii isiniif mijeessu.
Deutsch (German)
Wenn Sie Deutsch sprechen, stehen für Sie kostenlos Sprachassistenzdienste zur Verfügung. Wenn
Sie diese Dienste in Anspruch nehmen möchten, wenden Sie sich bitte an das Büro Ihres
Leistungserbringers. Dort wird man die Sprachassistenzdienste gerne für Sie arrangieren.
فارسی (Farsi)
اگربھزبانفارسیصحبتمیکنید،رسویسکمکزبانیبھصورترایگاندردسرتسشامخواھدبود.اگربھاینرسویس
ھانیازدارید،بادفرتارائھدھندهخدماتمتاسبگیرید.آنھاحتامًمقدماتالزمرابرایدسرتسیبھرسویسھایزبانیدر
اختیارتان.قرارمیدھند
Français (French)
Si vous parlez français, des services d’aide linguistique gratuits sont à votre disposition. Si vous
nécessitez ces services, contactez le cabinet de votre prestataire de soins. Ils se feront un plaisir
d’organiser ces services linguistiques pour vous.
ไทย (Thai)
หากท่านพูดภาษาไทย จะมีบริการความช่วยเหลือทางด ้าน ภาษาโดยไม่มีค่าใช ้จ่าย
หากท่านต ้องการใช ้บริการดังกล่าว โปรดติดต่อสําานักงานผู้ให ้บริการดูแล ซึ่งพร ้อมที่จะจัดหา
บริการทางด ้านภาษาให ้แก่ท่าน