Atikokan General Hospital

Privacy Policy @ AGH

Privacy Policy

Atikokan General Hospital General Administration Manual Privacy & Security Subsection Policy

The Atikokan General Hospital (AGH) will ensure that all personal health information under its control will remain private and only be released with proper authorization. The AGH Privacy Policy is based on the Canadian Standards Association 10 Principles of Privacy and the Ontario Health Information Protection Act, 2004.

Accountability for Personal Information

Atikokan General Hospital (AGH) is responsible for personal information under its control and has designated an individual who is accountable for AGH's compliance with the following:

  • Accountability for AGH's compliance with the policy rests with the Chief Executive Officer, although other individuals within AGH are responsible for the day-to-day collection and processing of personal information. In addition, other individuals within AGH are delegated to act on behalf of the Chief Executive Officer, such as the Privacy Officer and the Privacy Team.
  • The name of the Privacy Officer designated by AGH to oversee its compliance with these principles is a matter of public record.
  • AGH is responsible for personal information in its possession or custody, including information that has been transferred to a third party for processing. AGH will use contractual or other means to provide a comparable level of protection while the information is being processed by a third party
  • AGH will implement policies and practices to give effect to this policy, including:
    • Implementing procedures to protect personal information
    • Establishing procedures to receive and respond to complaints and inquiries
    • Training staff and communicating to staff information about AGH's policies and practices
    • Developing information to explain AGH's policies and procedures-A copy of "Patient's Privacy Notice" (06-01-00-03) is available upon request


Identifying Purposes for the Collection of Personal Information

AGH collects personal information for the following purposes: for the delivery of direct patient care, the administration of the health care system, research, teaching, statistics, fundraising, and meeting legal and regulatory requirements.

  • The identified purposes are specified at or before the time of collection to the individual from whom the personal information is collected. Depending upon the way in which the information is collected, this can be done orally or in writing. An admission form, for example, may give notice of the purposes. A patient who presents for treatment is also giving implicit consent for the use of his or her personal information for authorized purposes.
  • When personal information that has been collected is to be used for a purpose not previously identified, the new purpose will be identified prior to use. Unless law requires the new purpose, the consent of the individual is required before information can be used for that purpose.
  • Persons collecting personal information will be able to explain to individuals the purposes for which the information is being collected.


Consent for the Collection, Use, and Disclosure of Personal Information

AGH recognizes that the knowledge and consent of the individual are required for the collection, use, or disclosure of personal information, except where inappropriate.

Note: In certain circumstances personal information can be collected, used, or disclosed without the knowledge and consent of the individual. For example, legal, medical, or security reasons may make it impossible or impractical to seek consent. When information is being collected for the detection and prevention of fraud or for law enforcement, seeking the consent of the individual might defeat the purpose of collecting the information. Seeking consent may be impossible or inappropriate when the individual is a minor, seriously ill, or mentally incapacitated. In addition, if AGH does not have a direct relationship with the individual, it may not be able to seek consent.

  • Consent is required for the collection of personal information and the subsequent use or disclosure of this information. Typically, AGH will seek consent for the use or disclosure of the information at the time of collection. In certain circumstances, consent with respect to use or disclosure may be sought after the information has been collected but before use (for example, when AGH wants to use information for a purpose not previously identified).
  • AGH will make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used. To make the consent meaningful, the purposes must be stated in such a manner that the individual can reasonably understand how the information will be used or disclosed.
  • AGH will not, as a condition of the supply of a product or service, require an individual to consent to the collection, use, or disclosure of information beyond that required to fulfill the explicitly specified and legitimate purposes.
  • The form of the consent sought by AGH may vary, depending upon the circumstances and the type of information. In determining the form of consent to use, AGH will take into account the sensitivity of medical and health information.
  • In obtaining consent, the reasonable expectations of the individual are also relevant. AGH can assume that an individual's request for treatment constitutes consent for specific purposes. On the other hand, an individual would not reasonably expect that personal information given to AGH would be given to a company selling health-care products.
  • The way in which AGH seeks consent may vary, depending on the circumstances and the type of information collected. AGH will generally seek express consent when the information is likely to be considered sensitive (e.g., genetic testing). Implied consent would generally be appropriate when the information is less sensitive. An authorized representative (such as a legal guardian or a person having power of attorney) can also give consent.
  • Individuals can give consent in many ways. For example:
    a) Consent may be given at the time an individual presents for or uses a health service-this is an implied consent;
    b) A check-off box may be used to allow individuals to request that their names and addresses not be given to other organizations. Individuals who do not check the box are assumed to consent to the transfer of this information to third parties; or
    c) Consent may be given orally when information is collected over the telephone.
  • An individual may withdraw consent at any time, subject to legal or contractual restrictions and reasonable notice. AGH will inform the individual of the implications of such withdrawal.


Limiting Collection of Personal Information

The collection of personal information will be limited to that which is necessary for the purposes identified by AGH. Information will be collected by fair and lawful means.

  • AGH will not collect personal information indiscriminately. Both the amount and the type of information collected will be limited to that which is necessary to fulfill the purposes identified.
  • Consent with respect to collection will not be obtained through deception.


Limiting Use, Disclosure, and Retention of Personal Information

Personal information will not be used or disclosed for purposes other than those for which it was collected, except with the consent of the individual or as required by law. Personal information will be retained only as long as necessary for the fulfillment of those purposes.

  • If using personal information for a new purpose, AGH will document this purpose.
  • AGH has policies and procedures in place with respect to the retention of personal information, which include minimum and maximum retention periods. AGH is subject to legislative requirements with respect to retention periods.
  • Personal information that is no longer required to fulfill the identified purposes will be destroyed as per the AGH "Destruction of Patient Records" policies & procedures.


Ensuring Accuracy of Personal Information

Personal information will be as accurate, complete, and up-to-date as is necessary for the purposes for which it is to be used.

  • The extent to which personal information will be accurate, complete, and up to date will depend upon the use of the information, taking into account the interests of the individual. Information will be sufficiently accurate, complete, and up to date to minimize the possibility that inappropriate information may be used to make a decision about the individual.
  • AGH will routinely update personal information when individuals presents for services.
  • Personal information that is used on an ongoing basis, including information that is disclosed to third parties, will generally be accurate and up to date.


Ensuring Safeguards for Personal Information

Security safeguards appropriate to the sensitivity of the information will protect personal information.

  • The security safeguards will protect personal information against loss or theft, as well as unauthorized access, disclosure, copying, use, or modification. AGH will protect personal information regardless of the format in which it is held.
  • The nature of the safeguards will vary depending on the sensitivity of the information that has been collected, the amount, distribution, and format of the information, and the method of storage. A higher level of protection will safeguard more sensitive information, such as medical and health records.
  • The methods of protection will include:
    a) Physical measures, for example, locked filing cabinets and restricted access to offices;
    b) Organizational measures, for example, limiting access on a "need-to-know" basis, and
    c) Technological measures, for example, the use of passwords, encryption, and audits.
  • AGH will make its employees aware of the importance of maintaining the confidentiality of personal information. As a condition of employment, all AGH employees/agents (e.g., employee, clinician, physician, allied health, volunteer, researcher, student, consultant, vendor, or contractor) must sign the AGH Confidentiality Agreement.
  • Care will be used in the disposal or destruction of personal information, to prevent unauthorized parties from gaining access to the information.


Openness About Personal Information Policies and Practices

AGH will make readily available to individuals specific information about its policies and practices relating to the management of personal information.

  • AGH will be open about its policies and practices with respect to the management of personal information. Individuals will be able to acquire information about its policies and practices without unreasonable effort. This information will be made available in a form that is generally understandable.
  • The information made available will include:
    a) The name or title and the address of the Privacy Officer, who directs AGH 's privacy policies and practices, and to whom complaints or inquiries can be forwarded;
    b) The means of gaining access to personal information held by AGH;
    c) A description of the type of personal information held by AGH, including a general account of its use;
    d) A copy of any brochures or other information that explains AGH 's privacy policies, standards, or codes, and
    e) What personal information is made available to related organizations.
  • AGH may make information on its policies and practices available in a variety of ways. For example, AGH may choose to make brochures available in its place of business, mail information to its clients, post signs, or provide online access.


Individual Access to Own Personal Information

Upon request, an individual will be informed of the existence, use, and disclosure of his or her personal information and will be given access to that information. An individual will be able to challenge the accuracy and completeness of the information and have it amended as appropriate.

Note: In certain situations, AGH may not be able to provide access to all the personal information it holds about an individual. Exceptions to the access requirement will be limited and specific. The reasons for denying access will be provided to the individual upon request. Exceptions may include information that is prohibitively costly to provide, information that contains references to other individuals, information that cannot be disclosed for legal or security reasons or information that is subject to solicitor-client or litigation privilege.

  • Upon request, AGH will inform an individual whether or not it holds personal information about the individual. AGH will seek to indicate the source of this information and will allow the individual access to this information. However, it may choose to make sensitive medical information available through a medical practitioner. In addition, AGH will provide an account of the use that has been made or is being made of this information and an account of the third parties to which it has been disclosed.
  • In providing an account of third parties to which it has disclosed personal information about an individual, AGH will attempt to be as specific as possible. When it is not possible to provide a list of the organizations to which it has actually disclosed information about an individual, AGH will provide a list of the organizations to which it may have disclosed information about the individual.
  • AGH will respond to an individual's request within 30 days. This can be extended by an additional 30 days with reasonable grounds communicated to the requestor. Cost to the individual will be as set out by hospital policy.
  • The requested information will be provided or made available in a form that is generally understandable. For example, if AGH uses abbreviations or codes to record information, an explanation will be provided.
  • When an individual successfully demonstrates the inaccuracy or incompleteness of personal information, AGH will amend the information as required. Depending upon the nature of the information challenged, amendment involves the correction, deletion, or addition of information. Where appropriate, the amended information will be transmitted to third parties having access to the information in question.
  • When a challenge is not resolved to the satisfaction of the individual, AGH will record the substance of the unresolved challenge. When appropriate, the existence of the unresolved challenge will be transmitted to third parties having access to the information in question.


Challenging Compliance with AGH's Privacy Policies and Practices

An individual will be able to address a challenge concerning compliance with this policy to the Privacy Officer or Chief Executive Officer.

  • AGH will put procedures in place to receive and respond to complaints or inquiries about its policies and practices relating to the handling of personal information. The complaint procedures will be easily accessible and simple to use.
  • AGH will inform individuals who make inquiries or lodge complaints of the existence of relevant complaint procedures. A range of these procedures may exist.
  • AGH will investigate all complaints. If a complaint is found to be justified, AGH will take appropriate measures, including, if necessary, amending its policies and practices.

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