Confidentiality Policy
Section 1: General
This policy applies to Hassle Free Clinic’s (“HFC” or the “Clinic”) permanent site and all of its outreach sites and programs. It applies to the care of any person who is a past or present client/patient of HFC. This policy covers the collection, use and disclosure of personal health information.
Personal Health Information (PHI)
This includes identifying information about an individual in oral, recorded or electronic form that:
Relates to her or his physical or mental health
Relates to providing health care, including identifying a provider of health care
Relates to payments or eligibility for health care for an individual
Is a health number
Identifies her or him as a patient of the Clinic
Section 2: Custodian
Jane Greer is the Health Information Custodian for Hassle Free Clinic. This means, under the Personal Health Information Protection Act, 2004 (PHIPA) Ms. Greer has the responsibility to ensure that personal health information is collected, used, stored and shared with full regard for the protection of privacy and the confidentiality of personal health information. This obligation to protect the privacy of PHI extends to all physicians, staff, volunteers, students, residents, researchers, computer support people and anyone else visiting the Clinic or participating in its programs off site.
It should be noted that positive laboratory results of reportable diseases go directly to the Public Health Department as mandated by the Health Protection and Promotion Act of Ontario. The collection, use and disclosure of PHI in these circumstances by public health staff are beyond the authority of the Clinic.
It should also be noted that exemptions to this policy may be made by physicians and/or staff in the case of suspected physical or sexual abuse of a minor child, as mandated by the Child and Family Services Act.
Section 3: Collection
The Clinic collects personal health information from clients and other authorized persons to provide care, promote health and to prevent disease. The kind of personal health information collected may include:
Name, address, date of birth and Ontario health card number, or other health insurance information
Facts about health history, health care and current concerns
Information about payment for health care, when required for certain Clinic services
Personal health information may be collected in person, on the phone, through written or electronic documents. All documentation of personal health information by the Clinic is recorded on paper and/or electronically and will not be disclosed except as outlined below. The Clinic undertakes to secure its paper and electronic files through security systems.
Section 4: Use
Personal health information will not be disclosed except under the following circumstances.
To The Patient
A client may view her or his chart on Clinic premises without charge. The patient may also obtain a copy of their chart. The Clinic may require reasonable notice to respond to a request for photocopying.
Clients can receive test results or other information by telephone. When giving test results, staff will ask for a birth date in addition to the patient’s name. Anonymous HIV test results should always be given in person except in the most extraordinary circumstances. In order to obtain these results by phone, the patient must provide a unique identifier while on Clinic premises, in addition to the Anonymous HIV # and date of birth.
Hassle Free will not communicate test results to patients via electronic means. If that is the preferred/only method of contact with patients, the Clinic may choose to e-mail patients but only to ask them to contact the Clinic in person or by telephone. The Clinic may make exceptions to this in extraordinary circumstances where differing abilities make phone or in person contact impossible.
To Health Care Providers
Personal Health information relating to a patient can be shared among Clinic physicians, staff and volunteers in order to provide health care.
Personal health information relating to a client may be shared with other health care providers only on the basis of informed consent. If the sharing of the information is for the purposes of making a referral, and the client has consented to the referral process, then written patient consent is not required. Otherwise, a written consent form that specifies what information is to be released and to whom, signed by the client and witnessed and dated, should be obtained.
To Authorized Representatives of the Patient
Personal health information relating to a patient may be disclosed to an authorized representative of a patient only on the basis of a consent form that specifies what information is to be released and to who, is signed by the patient, witnessed and dated. HFC may, but is not required to, seek confirmation of the authority of the personal representative by checking with the patient.
HFC may charge for photocopying and delivery if applicable.
In response to a Summons or other Court Application
Personal health information may be subject to disclosure obligations imposed by law, i.e. the patient is or becomes involved in legal proceedings to which the information is relevant.
HFC will not disclose personal health information immediately upon receipt of the summons or other court application.
If HFC receives a summons or other court application seeking the disclosure of personal health information, all related records will be removed from regular Clinic use and placed in a sealed envelope. HFC will immediately assert privilege over the records, and will use its best efforts to ensure that the question of whether the records must be disclosed is determined by the relevant court or tribunal.
HFC will determine whether it is in proper receipt of the summons or other court application, and will use best efforts to ensure the patient to whom the records relate is notified that the summons or other court application has been received by HFC and of its contents, so that they may take steps to protect his or her privacy interests.
HFC will determine its position as to the disclosure of personal health information at issue considering the interests of the patient, the Clinic and applicable law.
HFC will attend before the relevant court or tribunal to make submissions as to whether the sealed records must be disclosed by HFC and, if so, to what extent.
In pursuing the steps set out above, HFC will seek the advice of legal counsel.
Section 5: Access
Patients who wish to access or correct their personal health information, or who have questions about how it is collected, maintained, used or disclosed, are encouraged to discuss this with their health care provider at the Clinic.
However, patients may also make a written request for access or to correct personal health information under PHIPA, through the Health Information Custodian, or her delegate.
Section 6: Complaint Policy and Procedures
Hassle Free Clinic is committed to the consistent provision of high-quality service to all of its patients/clients. If, however, service users feel negatively about their experience with the Clinic, they may wish to express their concerns as a complaint.
Staff will assist patients when requested to ensure this policy is accessible to all. This policy and its procedures will be available in accessible formats. Options for communication may vary depending on patient accessibility needs.
Any concerns expressed about care while patients are at the Clinic will be dealt with immediately to attempt a satisfactory resolution.
Patient/Client is anyone who receives services from Hassle Free, including but not limited to: one-on-one care, workshop activities, ‘speaks’, outreach activities and group programs delivered on or off site.
The Complaints Officer (CO) will be a Clinic Director or their delegate. The role of the CO is to oversee the handling of concerns in a timely and consistent manner and to keep all documentation. Only complaints where the complainant has identified themselves are covered by this policy. If anonymous complaints are received, the CO and relevant staff will review the concern, but will not act on it.
Informal Complaints
There may be times when a patient has a concern but does not wish to document it. An informal complaint may be mediated by a staff person to attempt an immediate resolution. If a resolution is found, the staff person will document the incident and inform the CO. If a complaint is made to a volunteer, student, resident, etc. they will refer the complainant to a staff person
Formal Complaints
A formal complaint is defined as one received in writing. If a complaint is given verbally, and is not resolved at an informal level, patients will be asked to put it in writing for the Clinic to review. If a patient requests assistance with this, the staff person taking the complaint will write down the complainant’s version of events and have them sign and date it.
When a written complaint is received, it will go to the CO. They will respond in a timely manner to tell them we are reviewing. The CO will talk to the people involved, obtain input from staff, and draft an appropriate written response, as well as having a conversation if appropriate. The person(s) involved will generally be made aware of the response. This process will happen as quickly as possible. If deemed necessary, the CO will contact the Clinic’s lawyer and Insurance Broker. Physicians named in complaints will be advised to contact the Canadian Medical Protective Association.
If a patient is not satisfied with the response from the Clinic, they have the right to appeal in writing to the Board of Directors.
If the complaint is regarding the Complaints Officer, it will be referred to the other Director and other staff or Board members as appropriate.
Ending the Clinic/Client Relationship
In rare circumstances, Clinic staff may decide to discontinue providing services to a patient. This may occur if there has been any action by a patient described in our Violence and Harassment Policy, through in-person, telephone or electronic communication. It may also occur because of a breakdown in trust between the Clinic and patient.
The Clinic will notify the patient in writing that Hassle Free will no longer provide services. We will inform them that we will transfer their records upon request with proper documentation. We will also give them the contact information for Telehealth Ontario to find alternative care if needed. If there are outstanding prescriptions, we will transfer them to a pharmacy as instructed by the patient. If there are abnormal test results, we will try to notify the patient so they can obtain appropriate follow up from another provider.
Approved by the Board of Directors:
November 24, 2010
Reviewed: 2013
2017
2021