Penobscot Valley Hospital Notice of Privacy Practices January 1, 2017

This condensed Notice describes how medical information about you may be disclosed and how you can get access to this information.

Click here for a PDF version of this notice.

Types of Uses and disclosures of medical information
  • Appointment Reminders 
  • Inmates/Law Enforcement 
  • As Required by Law
  • Laws and Disputes 
  • Public Interest/Research
  • National Security & Intelligence Activities
  • To Avert Serious Threat to Health or Public Safety
  • Birth Announcements
  • News Media
  • Coroner/Medical Examiner
  • Military & Veterans
  • Workers’ Compensation
  • Health Oversight Activities as Required by Law
  • Fund-raising Activities
  • Public Health Risk/Public Record
  • Funeral Directors
  • Organ and Tissue Donation
  • Health-related Benefits & Services
  • Individuals involved in your Care or Payment of Care 
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 permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.

Your rights regarding information we maintain about you
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 or for the hospital. Your request to amend your medical information must be in writing.

Right to Inspect & Copy: You have the right to inspect and copy 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 copy medical information that may be used to make decisions about you, you must submit your request in writing. Your request may be denied in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to an Electronic Copy of Your Medical Record: You have the right to all electronic protected health information maintained in any designated record set. We must allow you access to your own protected health information in the electronic form and format requested, unless the material cannot be readily provided in that format. In that case we would provide you with the information in a legible electronic format. If you decline the electronic format that we can provide, we will comply with the request for an electronic copy of your medical record by providing a hard copy of the protected health information.

Right to an Accounting of Disclosures: You have the right to an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing. 

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 healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. (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 with emergency care). We cannot deny your request when the disclosure is for a purpose other than “treatment,” and the individual has paid in full for the service. In this instance, the covered entity is required to comply with the request to restrict access to the protected health information. 

Immunization Records: We may disclose proof of immunization to a school when this information is required prior to student admission. Written authorization is no longer required. We may obtain verbal authorization from the individual (if an adult or emancipated minor) or a parent, guardian, or any other person standing in the place of the student’s parent.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

Right to a Paper Copy of this Notice: You have the right to a paper copy of the complete Notice of Privacy Practices in its entirety. You may ask us to give you a copy of the complete Notice of Privacy Practices, including specific disclosure examples, at any time. You may also obtain a copy of the complete Notice of Privacy Practices on our website:

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health & Human Services. To file a complaint with Penobscot Valley Hospital, contact the Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

How we may use or disclose medical information about you
The following categories describe different ways we may use and disclose medical information. Not every use or disclosure in the category will be listed. However, all the ways we are permitted to use or disclose information will fall into one of these categories:

For Treatment: We may use medical information about you for medical treatment or services. We may disclose medical information about you to physicians, mid-level providers, nurses, technicians, medical students, or other Hospital personnel who are involved in taking care of you in the Hospital.

For Payment: We may use and disclose medical information about you so that the treatment and services you receive at the Hospital may be billed and payment may be collected from you, an insurance company, or a third party.

For Healthcare Operations: We may use and disclose medical information about you for Hospital operations. These uses and disclosures are necessary to run the Hospital and make sure that all our patients receive
quality care.

Notice of Breach: The final HIPAA Privacy and Security Rule requires that you be told about any breach of your unsecured protected health information by receiving written notification from the Hospital. If your “limited data set” is impermissibly disclosed, the hospital must perform a risk assessment to determine if a breach notification is required, even if the limited data set does not contain a birth date or zip code. (Please see the Complete Notice of Privacy Practice for more information regarding breach of information.

For HealthInfoNet: Penobscot Valley Hospital participates in the statewide health information exchange (HIE) designated by the State of Maine. The HIE is a secure computer system for healthcare providers to share your important health information to support treatment and continuity of care. For example, if you are admitted to a healthcare facility not affiliated with ours, health care providers there will be able to see important health information held in our electronic medical record systems.

Your record in the HIE includes medicines (prescriptions) lab and test results, imaging reports, conditions, diagnoses or health problems. To ensure your health information is entered into the correct record, also included are identifiers such as your full name, birth date, and social security number. All information contained in the HIE is kept private and used in accordance with applicable state and federal laws and regulations. The information is accessible to participating providers to support treatment and healthcare operations such as mandated disease reporting to the Maine Centers for Disease Control and Protection.

You do not have to participate in the HIE to receive care. For more information about HIE and your choices regarding participation, visit or call toll-free 1-866-592-4352.

Changes to this Notice
Penobscot Valley Hospital reserves the right to change this Notice. We also 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 Hospital with the current effective dates.

Who Will Follow this Notice: This Notice describes our Hospital’s practices and that of:
  • Any healthcare professional authorized to enter information into your hospital chart
  • All departments and units of the Hospital
  • Any member of a volunteer group we allow to help you while you are in the Hospital
  • All employees, hospital-based physician practices, staff, and other hospital personnel
  • All owned subsidiary practices of Penobscot Valley Hospital will follow this Notice
All these entities, sites, and locations may share information with each other for treatment, payment or healthcare operations purposes described in this Notice.

Our Pledge Regarding Information
We understand that medical information about you and your health is personal. We are committed to protecting your information. We create a record of care and services you receive at the Hospital. 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 of your care generated at the Hospital, whether made by Hospital personnel or your personal physician. Your personal physician may have different policies and notices regarding the use and disclosure of your medical information created in his/her office or clinic.

We are Required by Law
  • To make sure that medical information that identifies you is kept private;
  • To give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
  • To follow the terms of the Notice that is currently in effect.

If you have questions about this Notice, please contact:
Health Information Management at Penobscot Valley Hospital 
P.O. Box 368 / 7 Transalpine Road, Lincoln, Maine 04457
Telephone Number : (207) 794-7139


Nondiscrimination Policy

Discrimination is Against the Law

As a recipient of Federal funding, PVH does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, gender identity or expression, genetic information, Vietnam or other veteran status or any other status protected by the relevant law in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein, whether carried out by Penobscot Valley Hospital directly or through a contractor, or any other entity with whom PVH arranges to carry out its programs and activities. 
Penobscot Valley Hospital:

Provides free aids and services to people with disabilities to communicate effectively with us, in a timely and accurate manner while protecting the privacy such as:
  • Qualified sign language interpreters
  • Information in other formats (large print, audio, accessible electronic formats)
Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters and translators
  • Information written in other languages
If you need these services, contact PVH Registration or call 207-794-3321.

If you believe that PVH 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 with: Gary R. Poquette, PVH Chief Executive Officer, P.O. Box 368, Lincoln, Maine 04457, phone 207-794-7127, TTY 207-794-7341, 
fax 207-794-6488, or email You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Gary R. Poquette, CEO 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, electronically through the Office for Civil Rights Complaint Portal, available at, 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
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at 
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Appelez le 207-794-3321 (ATS: 207-794-7341).

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ียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-207-794-3321  (TTY: 1-207-794-7341).

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