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HIPAA Privacy
Keystone Health, through its entities; Keystone Pediatric Developmental Center, Keystone Behavioral Health, Keystone Crisis Intervention, Keystone Dental , Keystone Family Medicine, Keystone Community Health Services (Infectious Disease & Community Outreach Program), Internal Medicine, Keystone Pediatrics, Keystone Urgent Care, Women’s Care, Keystone Agricultural Worker Program, Keystone Foot and Ankle, Keystone Chiropractic, is committed to protecting medical information about you.
All of these entities, sites and locations follow the terms of the Notice of Privacy Practices English Version | Spanish Version (PDF). This notice, in compliance with federal privacy regulations, describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. In addition, Keystone entities may share medical information with each other for treatment, payment or healthcare operation purposes described in this notice.
RELEASE OF INFORMATION FORMS:
- Requests to release your health information may be done by completing the “Authorization to Use or Disclose Health Information” English Version | Spanish Version and forward it to the Keystone’s Health Information Department
- To request a copy of your own health record or that of your child/dependent, please use the “Patient request to Access Medical Records” form. English Version | Spanish Version and forward it to the Keystone ‘s Health Information Department. Many components of the electronic health record are made available to patients on the secure MyKeystone patient portal.
If you are requesting medical records from the Keystone Health, Health Information Department for a deceased loved one, you may be asked to also complete a “Next of Kin Verification Form” English Version | Spanish Version and forward it to the Keystone’s Health Information Department.
If you need to request a correction to your medical record, please complete the “Request for Amendment of the Health Record” Form English Version | Spanish Version and forward it to the Keystone’s Health Information Department.
If you would like to revoke a previously signed authorization please complete the “Request for Revocation of Authorization form” English Version | Spanish Version and forward it to the Keystone Health, Health Information Department.
If you would like to request specific restrictions to how we share your health information, please complete the “Request for Restrictions” form English Version | Spanish Version and forward it to the Keystone’s, Health Information Department.
A patient has the right to receive a written Accounting of Disclosures of their protected health information (PHI) made by Keystone Health in the six years prior to the date of which the accounting is requested. (45 CFR § 164.528). A patient may request an accounting of a period of time less than six years. If you would like to request an Accounting of Disclosures please complete the “Accounting of Disclosures Request form” English Version | Spanish Version and forward it to the Keystone Health, Health Information Department.
If you would like to give consent for another family member or friend to bring your child into Keystone for an office visit in your absence, complete the “Parental permission” form English Version | Spanish Version and forward it to the Keystone Health, Health Information Department.
To give access to your health information to family members and friends who are a part of your health care treatment, please complete the “Permission to Communicate” form English Version | Spanish Version and forward it to the Keystone Health, Health Information Department.
If you are making healthcare decisions for an adult family member with a disability and the incapacity to make their own healthcare decisions, you may be authorized to become that person’s “Healthcare Representative. Per Pennsylvania law (Act 2006-169, 20 Pa. Cons. Stat. Ann. § 5461) a “health care representative” is authorized to make health care decisions for a disabled/incapacitated adult family member. You may complete this form English Version | Spanish Version and forward it to Keystone Health Center’s Health Information Department. For additional information, please follow this link https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:2b12f5ae-eaf3-4280-b75f-1ee015fc3312
Your health information may be shared with other treating providers through an HIE. Health information exchange is an organization that regional health care providers participate in to exchange patient information to facilitate health care, avoid duplication of services (such as tests) and to reduce the likelihood that medical errors will occur. The HIE allows patient health information to be shared among authorized health care providers (such as health systems, hospitals, physician offices and labs) and health information organizations for Treatment, Payment and Operations (TPO) purposes. The HIE is a secure electronic system designed according to nationally recognized standards, and in accordance with federal and state laws that protect the privacy and security of the information being exchanged. Patient health information shall be available to authorized health care providers through the HIE unless you as a patient declines to participate, or ‘opts-out’ by completing a “Health Information Exchange Patient Opt-Out Form” English Version | Spanish Version and forward it to the Keystone Health, Health Information Department.
All form listed above may be submitted to Keystone’s Health Information Management Department by the following methods:
Email: khc-him@keystonehealth.org
Mail: 111 Chambers Hill Drive, Suite 200 Chambersburg, PA 17201
Fax: 717-217-1937
You can learn more about federal privacy regulations from the U.S. Department of Health & Human Services’ Office for Civil Rights.
