You Have the Right to the Best Care. At Loretto Hospital, our goal is to make your visit as pleasant as possible. We recognize and are committed to your individual rights as a patient. Patients, or their designated representative, are involved in decisions regarding the care that we deliver to the extent this is practical and possible. We seek to inform you about options to care and risks associated with the care you seek. We will constantly try to understand and respect your objectives for care. We hope the mutual understanding of these rights and responsibilities will contribute to the best possible patient care and satisfaction. By understanding your rights and responsibilities, you can help us, help you.
Patients Rights and Responsibilities Handbook (English)
Patients Rights and Responsibilities Handbook (Spanish)
PATIENTS' RIGHTS AND RESPONSIBILITIES
As a patient at Loretto Hospital, you have the right to:
Reasonable access to care
- Care that is considerate and respectful of your personal values and beliefs
- Know the identity and professional status of individuals providing care to you
- Privacy, confidentiality and security
- An environment that is respectful, courteous, and preserves your dignity
- Be free from mental, physical, sexual and verbal abuse, neglect and exploitation
- Expect confidentiality regarding your records, condition and treatment, to have access to your medical records in keeping with hospital policy, and to have them explained to you
- Be informed regarding the nature of your condition, proposed treatment, procedures and prognosis in terms and in the manner you understand
- Participate actively in decisions regarding your medical care
- Know about alternative methods of treatment, their risks and advantages
- Refuse treatment to the extent permitted by law and be informed of the medical consequences of such action
- Have your pain assessed and treated appropriately
- Refuse participation in any treatment considered to be experimental in nature
- Obtain information as to any relationship between the hospital and other healthcare and/or educational institutions
- You have the right to know the nature of the professional relationships between individuals who are treating you
- Formulate and receive treatment based on your advanced directives
Examine and receive an explanation of your bill regardless of the source of payment to the extent permitted by law
- Receive information regarding your continuing health care requirements following discharge from the hospital
- Information about the hospital’s process for the initiation, review and resolution of patient grievances. (To file a complaint or grievance that cannot be immediately resolved, contact the Patient Experience Officer through the operator or by phone at 773- 854-5064).
- Be free from restraints of any form that are not medically necessary or as a means of punishment, coercion, retaliation, discipline, or for the convenience of staff. (Restraints will only be used after other efforts have been exhausted).
As a patient at Loretto Hospital, you have the right to:
- Provide accurate and complete information, to the best of your knowledge, concerning your present and past illnesses, hospitalizations, medications and other information relating to your health
- Ask questions if you do not clearly understand information and instructions about your treatment and care
- Follow the instructions and treatment plan coordinated by your physician
- Be considerate and respectful to our caregivers, other patients, and visitors to the hospital
- Present to the hospital a copy of your Living Will or Power of Attorney for Healthcare so that your Advanced Directives can be honored
- Be responsible for your own actions if you refuse treatment or refuse to follow your treatment instructions
- Cooperate in your discharge planning
- Report changes in your condition to those responsible for your care
- Honor the confidentiality and privacy of other patients
- Follow hospital rules and regulations
- Ensure that payment for your care is made promptly and in full. This means understanding your insurance coverage and its limits, and any added responsibilities you may have.
- Comply with this policy by respecting patient's rights and reinforcing patient's responsibilities
Loretto Hospital Notice of Privacy Practices
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.
This notice describes how we may use and disclose protected health information about you. Protected health information means any health information that could be used to identify you. In this notice, we refer to all of that protected health information as “PHI.” This notice also describes your rights and our duties with respect to your PHI. In addition, it tells you how to complain to us if you believe we have violated your privacy rights.
We are committed to the protection of PHI in accordance with applicable laws and accreditation standards regarding patient privacy. Your PHI is personal. A record of the care and services you receive at our facility is needed to provide you with quality care and to comply with legal requirements. The law requires us to make sure that your PHI is kept private. The law also requires us to provide a copy of this notice which explains our legal duties and privacy practices with respect to your PHI, and to follow the terms of this notice currently in effect.
How We May Use and Disclose Your PHI
We use and disclose your PHI for a number of different purposes. Each of those purposes is listed below.
We may use your PHI to provide, coordinate or manage your inpatient, outpatient, or post-hospital care. We may disclose your PHI to doctors, nurses, hospitals and other healthcare facilities who become involved in your care. In the course of your treatment here, your PHI may be disclosed to indirect healthcare providers such as our independent contractor radiologists and pathologists. Similarly, we may refer you to another healthcare provider and as part of the referral process share your PHI with that provider. An example of this would be if you were being treated for a broken leg, and the physician needed to know if you had diabetes, because diabetes may slow the healing process. So the physician treating your leg may refer you to another physician who specializes in treating diabetic patients and in doing so, will share your PHI with that physician. Additionally, if you have diabetes, the physician will share your PHI with a dietitian so we can arrange for appropriate meals for you.
We may use and disclose your PHI so we
can be paid for the services we provide. This can include billing you, your
insurance company, or a third party payor. For example, we may need to give
your insurance company information about the healthcare services provided to
you such as your dates of admission and discharge so that your insurance
company will pay us for those services or reimburse you for money that you have
paid. We may also provide your name, address and insurance information to other
healthcare providers who care for you while you are being treated here so that
they may submit bills for their care. Additionally, we may need to provide your
insurance company or a government program such as Medicare or Medicaid with
information prior to your admission about your medical condition and the
treatment you need to determine if you are covered in the event of planned
care, under that insurance program.
3. Healthcare Operations
We may use and disclose your PHI for our
own healthcare operations. These uses and disclosures are necessary to run our
organization and to make sure that all of our patients receive quality care and
cost-effective services. For example, we may use PHI to review the quality of
our treatment and services, to develop new programs, to determine whether new
treatments are effective, and to evaluate the performance of our staff in
caring for you. We may use PHI to contact you after your discharge from our
care to discuss satisfaction with your stay with us and your current health
status. Additionally, we may share your PHI with accrediting and licensing
bodies in order to continue to be a licensed and accredited healthcare
facility. We may also combine your PHI with PHI from other healthcare
organizations to improve our services. When we do so, we may remove information
that identifies you as an individual from the shared PHI. We may also share
your PHI with other healthcare organizations who have or have had a
relationship with you if that information is related to and needed for the
healthcare operations of the other healthcare organization.
4. Hospital Directory
We may include your name, date of admission, and location in our facility in our directory while you are a patient in our facility. This information may be released to people who ask for you by name. Additionally, during the registration process, you will be asked your religious affiliations, if any. Your religious affiliation may be given to member of the clergy, such as a minister, priest, or rabbi, who asks for you by name, or who asks for a list of patients who are members of their church, synagogue, or parish. If a telephone call or delivery arrives for you, we may acknowledge that you are a patient in our facility, and either transfer the call to you or accept the delivery on your behalf. If a delivery arrives for you after your discharge from the hospital, we will direct the party making the delivery (for example, a florist or the United States Postal Service) to forward the item being delivered to your home address. If you do not want items forwarded to you home address after your discharge, please notify the registration and admitting staff of an alternative forwarding address.
Should your stay with us attract media attention (for example if you are involved in an accident or if you are a celebrity) we will follow the Hospital policy for release of information to the media. If you want us to withhold information from the media, please advise registration and admitting staff of your request. If you do not want to be included in our directory, or you want to restrict the information we include in the directory, please notify the registration and admitting staff and they will assist you with your request.
5. Appointment Reminders
We may use and disclose PHI to contact
you to remind you of an appointment you have with us. We may contact you by
telephone or my mail at either your home or your office. We may, at your
request, leave messages for you on the answering machine or voicemail. If you
want to request that we communicate to you in a certain way or at a certain
location, please contact Loretto Hospital’s Privacy Officer.
6. Health Related Benefits, Services, and Alternatives
We may use and disclose your PHI to
contact you about health-related benefits, services and treatment alternatives
that may be of interest to you.
7. Fundraising and Marketing
We may use your PHI to contact you in an
effort to raise money for the Hospital and its operations. We may also disclose
health information to the Loretto Hospital Foundation so that the Foundation
may contact you to raise money for the Hospital. We would only release contact
information, such as your name, address, phone number, and the dates you
received treatment or services at the Hospital. If you do not want the Hospital
to contact you for fundraising efforts, you must notify the Hospital’s Privacy
Officer in writing. In addition, the Hospital may use your health information
for marketing, but will require your authorization to do so for marketing
communication other than those that describe our services, or those that relate
to your treatment or care coordination. For example the Hospital may send you
an announcement about a new service as part of a general mailing to all our
8. Individuals Involved In Your Care
We may disclose to a family member,
other relative, friend, or any other person identified by you, PHI that is
relevant to that person’s involvement in either your care or payment related to
your care. An example of this is a family member who accompanies you to the
hospital for a procedure and with whom the surgeon speaks regarding your
surgery. We may also use or disclose your PHI to notify, or assist in
notifying, those persons of your location, general condition, or death. If
there is a family member, other relative, friend or other person to whom you do
not wish us to disclose the above information, please notify the registration
or admitting staff, and the person who is providing care to you of your
9. Disaster Relief
We may use or disclose your PHI to a
public or private entity authorized by law or by its charter to assist in
disaster relief efforts. This will be done to coordinate with those entities in
notifying a family member, other relative, friend, or other person identified
by you of your location, general condition or death.
10. Public Health and Government Functions
We may disclose your PHI to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. We may disclose your PHI to the government or a health oversight agency for the following:
To control or prevent a communicable disease, injury, or disability.
To report electro-convulsive therapy treatment.
To refer patients admitted with a psychiatric diagnosis to Behavioral Health.
To report births and deaths.
To reports adverse reactions that may occur after administering a vaccine, drug or treatment to a patient.
To report instances of food poisoning or product defects.
To track products and enable product recalls.
To conduct post procedure follow-ups as required by law.
11. Required By Law
We are required by law to release your PHI as it relates to:
A federal, state, county or law enforcement agency regarding reporting, investigating or prosecuting threatened or suspected child or elder abuse, domestic violence, or relinquishment of an infant 72 hours old or less.
An agency or law enforcement agency investigating abuse, neglect, physical injury, violent crimes, death, animal bites, injuries due to the discharge of a firearm, and the inappropriate transfer of a patient by another facilities’ emergency department.
Your court appointed guardian.
An agent you appoint under a healthcare power of attorney.
The appropriate law enforcement official or correctional institution if you are in custody or incarcerated.
12. Judicial and Administrative Proceedings
We may disclose your PHI in the course
of any judicial or administrative proceeding in response to an order of the
court or administrative tribunal. We may also disclose your PHI in response to
a subpoena, discovery request, or other legal process but only if efforts have
been made to tell you about the request, it appears from the request that you
know of its existence, or an order is obtained protecting the information to be
13. Law Enforcement Purposes
We may disclose your PHI to a law enforcement official for the following law enforcement purposes:
As required by law, in response to a court, grand jury, or administrative order or subpoena,
To identify a suspect, fugitive, material witness, or missing person, about an actual or suspected victim of a crime.
Regarding a death if we suspect the death may have resulted from criminal conduct,
About crimes that occur at our facility, and
To report a crime in emergency circumstances.
14. Coroners, Medical Examiners and Funeral Directors
We may disclose your PHI to a coroner or
medical examiner for purposes such as identifying a deceased person or
determining cause of death. We may disclose your PHI to a funeral director in
the event of your death.
15. Organ Eye or Tissue Donation
We may disclose your PHI to organ
procurement organizations or other entities engaged in the procurement, banking
or transplantation of organs, eyes or tissues.
Under certain circumstances, we may
disclose your PHI for research. For example, a research project might compare
the health and recovery of all patients who received one medication to those
who received another medication for the same condition. For this type of
project, we remove information that identifies you from your PHI. In all other circumstances,
you will be asked to give your consent to participate in a research project.
You may choose not to participate in a research project and your care and
treatment will not be affected by your decision. All research projects are
approved through a process that evaluates the needs of the research project
with your need for protection of PHI.
17. Serious Threat to Health or Safety
We may use or disclose your PHI if we
believe the use or disclosure is necessary to prevent or lessen a serious or
imminent threat to the health or safety of a person or the public. We may also
release information about you if we believe the disclosure is necessary for law
enforcement authorities to identify or apprehend an individual who admitted
participation in a violent crime or who is an escapee from a correctional
institution or from lawful custody.
If you are a member of the Armed Forces,
we may use and disclose your PHI for activities deemed necessary by the
appropriate military command authorities to assure the proper execution of the
military mission. We may also release information about foreign military
personnel to the appropriate foreign military authority for the same purposes.
19. National Security
We may disclose your PHI to authorized
federal officials for the conduct of intelligence, counter-intelligence, and
other national security activities authorized by law. Additionally, we may also
disclose your PHI to authorized federal officials so they can provide
protection to the President of the United States, certain other federal
officials, or foreign heads of state. We may use your PHI to make medical
suitability determinations and may disclose the results to officials in the
United States Department of State for purposes of a required security clearance
or service abroad.
20. Inmates and Persons in Custody
We may disclose your PHI to a
correctional institution or law enforcement official having custody of you. The
disclosure will be made if it is necessary to provide healthcare to you, for
your health and safety, the health and safety of others, or the safety,
security and good order of the correctional institution.
21. Workers Compensation
We may disclose your PHI to the extent
necessary to comply with workers compensation and similar laws that provide
benefits for work related injuries or illness.
22. Other Uses and Disclosures
Other uses and disclosures will be made
only with your written authorization. You may revoke such authorization at any
time by notifying Loretto Hospital’s Privacy Officer, Tina Holder, at 645 S.
Central Avenue, Chicago, IL 60644 or by calling (773) 854-5380 of your desire
to revoke it. If you revoke such an authorization, however, it will not have
any effect on actions taken in reliance upon it. In all instances where we use
or disclose your PHI, we follow a “Minimum Necessary” standard. Each person
accessing your PHI makes every reasonable effort to limit the use and
disclosure of your PHI to that information to accomplish the intended purpose
YOUR PROTECTED HEALTH INFORMATION (PHI) RIGHTS
1. Right to Request Restrictions
You have the right to request that we
restrict the uses or disclosures of your PHI to carry out treatment, payment or
healthcare operations. You also have the right to request that we restrict the
uses or disclosures we make to someone who is involved in your care or the
payment for your care. We are not required to agree to your request if it
inhibits the provision of patient care, treatment, payment, or healthcare
If we do agree to the restriction, we
will comply with your request unless the information is needed to provide you
emergency treatment. If we agree to a restriction and later disclose your PHI
for emergency treatment purposes to another provider, we will ask that provider
not to use or disclose the information other than for treatment purposes. A
request for a restriction should be made in writing to the Medical Records
Department. Your request should specify what information you want to limit,
whether you want to limit use or disclosure or both, and to whom you want the
limits to apply.
If we agree to a restriction, you can
request orally or in writing that we end that agreement and lift the
restriction. If you make an oral request, we will document that you requested
that the restriction be lifted in your medical record. We may also decide to
end the agreement and lift the restriction and if we decide to do so we will
advise you of our decision.
2. Right to Inspect and Copy
You have the right to inspect and obtain
a copy of your health records with limited exceptions as allowed by law. While
you are an inpatient, your request to inspect your records may be made to your
nurse or physician. After discharge your request should be made to the Medical
Records Department. To obtain a copy of your health records, you must complete
an authorization form and submit it to the Medical Records Department. To
obtain a copy of your billing information, you must contact the Patient
Financial Services Department. We will respond to your request within 30 calendar
days of receipt of the completed authorization form.
We may deny your request to inspect and
copy your health records if the information involved is psychotherapy notes. We
may also deny a request by you or your legal representative to inspect and copy
your PHI if doing so may endanger the life or physical safety of you or another
If we deny your request, in its entirety
or in part, we will inform you in writing of the basis of the denial, how and
under what circumstances you may have your denial reviewed, and how you may
complain. If you request a review of our denial, it will be conducted by a
licensed healthcare professional designated by us who was not directly involved
in the denial. We will comply with the outcome of that review.
3. Right to Amend
You have the right to ask us to amend
your PHI as long as the PHI is maintained by us. You may request an amendment
by notifying the Medical Records Department of your desire to amend the record
and completing the "Amendment Form" utilized for that purpose. The
Medical Records Department will provide a written response to your request
within 30 calendar days of receipt of the completed "Amendment Form."
We may deny your request if we determine that your PHI: a) was not created by
us, b) is not part of the record set, c) is protected from access by law, or d)
we believe your PHI is accurate and complete.
4. Right to a List of Disclosures
You have the right to receive a list of disclosures made of your PHI. Certain types of disclosures are not included in that list such as disclosures to you or your legal representative, disclosures to carry out treatment, payment and healthcare operations, disclosures made as discussed in paragraphs 7, 8, 9 or 10 of this notice, or those disclosures made in response to a signed authorization. To request a list of disclosures, you should submit your request in writing to the Medical Records Department. Your request must indicate a time period for the disclosures.
The first list you request from us within a 12 month period will be provided at no charge. For additional lists, we may charge you for the costs associated with providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at the time before any costs are incurred.
The list of disclosures will include the following information about the disclosures:
the date the disclosure was made,
the name and address of the person or entity to whom it was made,
a brief description of what was disclosed, and
a brief statement of the purpose of the disclosure.
We will attempt to provide the list to you within 60 days after receipt of your request. If we are unable to do so within that time frame, we will let you know.
5. Right to Request Confidential Communications
You have the right to request that we
communicate with you about your PHI in a certain way or at a certain location.
For example, you may ask that we only contact you by mail or at work. Our
standard means of communication is in person, by telephone, or in writing. If
you wish to make a request for an alternative means of communication, you must
do so in writing to the Medical Records Department. Your request must state how
or where you can be contacted, but does not need to explain the reason for your
request. We will accommodate all reasonable requests.
6. Right to Revoke Authorization
Uses and disclosures of PHI not covered by this Notice of Privacy Practices or applicable laws will be made only with your written authorization. If you authorize us to use or disclose your PHI, you may revoke that authorization, in writing, at any time. We are unable to take back any disclosures we have already made with your permission. To revoke an authorization, you must contact the Medical Records Department.
7. Right to Complain
If you believe your privacy rights have
been violated, you may complain to the Hospital or to the United States
Department of Health and Human Services. To complain to the Hospital, please
contact Tina Holder, Privacy Officer at (773) 854-5380 and indicate that you
have a complaint regarding a breach of privacy. To complain to the United
States Department of Health and Human Services, contact the Office for Civil
Rights, U.S. Department of Health and Human Services, 200 Independence Avenue
SW, Washington, D.C., 20201. There will be no retaliation against you for
making your complaint.
Important Note Regarding This Notice of Privacy Practices
Loretto Hospital reserves the right to
change this Notice of Privacy Practices. We reserve the right to make the new
notice's provisions effective for all PHIs that we maintain, including that
created or received by us prior to the effective date of the new notice. A copy
of our current Notice of Privacy Practices will be posted in all patient
registration areas. In addition, each time you register at a site covered by
this notice, a copy of the current notice will be made available to you. If you
have any questions after reading this notice, please contact the Loretto
Hospital’s Privacy Officer, Tina Holder, at (773) 854-5380. You may also
contact the Confidential Compliance Hotline at (773) 854-5047.
Effective April 14, 2003. Revised May 7, 2014.
In order to guarantee the highest quality healthcare for our patients, Loretto Hospital participates in a national accreditation process conducted by the Joint Commission on Accreditation of Healthcare Organizations.
The Joint Commission is an independent, not-for-profit organization that sets national standards for measuring healthcare quality and safety, including the safety of the environment where healthcare is provided. The Joint Commission conducts routine unannounced accreditation surveys throughout the year at participating hospitals.
If you have questions or concerns about Loretto Hospital’s quality of care or safety, please contact our Patient Safety Officer at (773) 854-5609. You may also contact The Joint Commission at Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181. You may also contact The Joint Commission by calling (800) 994-6610 or via email firstname.lastname@example.org.
to review Loretto Hospital’s Accreditation Quality Report by the Joint Commission.
Illinois Hospital Report Card Act
As an Illinois consumer, you have a right to access information about the quality of health care provided in the State of Illinois. In response to the “Hospital Report Card Act” (HRCA), Loretto Hospital is hereby notifying the public of its right to access information on quality and safety data, nurse staffing, patient satisfaction and costs of services at hospitals and surgery centers in Illinois. This information can be obtained upon written request by contacting the Chief Nursing Officer at (773) 854-5305.
to learn more about the Illinois Hospital Report Card Act.
Right to an Interpreter
Health care facilities have a responsibility under federal law to be accessible to deaf and hard of hearing, as well as non-English speaking individuals. Loretto Hospital values the diversity of its patient base. In order to meet the widespread need of the Austin and surrounding communities, and to support our patients and their families, upon request we provide foreign and sign language interpreters as well as other auxiliary aids to patients. These services are provided at no additional cost to our patients.