Privacy Policy

Standard Statement:

The Sioux Lookout Meno Ya Win Health Centre will ensure that all Personal Information under its control will remain private and only be released with proper authorization.

Policy/Procedure:

Principle 1: Accountability for Personal Information

The Sioux Lookout Meno Ya Win Health Centre (SLMHC) is responsible for personal information under its control and has designated a Privacy Officer, who is accountable for SLMHC’s compliance with the following:

  • Accountable for the SLMHC's compliance with this policy rests with the Chief Executive Officer, although other individuals within the SLMHC are responsible for the day-to-day collection and processing of personal information. In addition, other individuals within SLMHC are delegated to act on behalf of the Chief Executive Officer, such as the Privacy Officer.
  • SLMHC is responsible for personal information in its possession or custody, including information that has been transferred to a third party for processing. The SLMHC will use contractual or other means to provide a comparable level of protection while the information is being processed by a third party.
  • SLMHC has implemented policies and practices to give effect to this policy, including:
    1. Implementing procedures to protect personal information.
    2. Establishing procedures to receive and respond to complaints and inquiries.
    3. Training staff and communicating to staff information about SLMHC's policies and practices.
    4. Developing information to explain SLMHC's policies and procedures, and providing interpreter services if required

Principle 2: Identifying Purposes for the Collection of Personal Information

The SLMHC 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. A written Consent, for example, may give notice of the purposes. A patient who presents for treatment is also giving implied consent for the use of his or her personal & health 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.

Principle 3: Consent for the Collection, Use, and Disclosure of Personal Information

The SLMHC recognizes that the knowledge and consent of the patient are required for the collection, use, or disclosure of personal information, except where appropriate.

Note: In certain circumstances personal information can be collected, used, or disclosed without the knowledge and consent of the patient. 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 SLMHC 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, the SLMHC 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 SLMHC wants to use information for a purpose not previously identified).
  • The Sioux Lookout Meno Ya Win Health Centre will make a reasonable effort to ensure that the patient 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.
  • The Sioux Lookout Meno Ya Win Health Centre will not, as a condition of service rendered, require a patient 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 SLMHC may vary, depending upon the circumstances and the type of information. In determining the form of consent to use, SLMHC will take into account the sensitivity of medical and health information.
  • In obtaining consent, the reasonable expectations of the patient are also relevant. SLMHC 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 SLMHC would be given to a company selling health-care products.
  • The way in which SLMHC seeks consent may vary, depending on the circumstances and the type of information collected. SLMHC 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.
  • Patients can give consent in many ways. For example:
    1. Consent may be given at the time that the patient uses a health service, and is an implied consent.
    2. Consent may be given orally when information is collected over the telephone, or
  • A patient may withdraw consent at any time, subject to legal or contractual restrictions and reasonable notice. SLMHC will inform the individual of the implications of such withdrawal. If a patient chooses to withdraw consent for information to be sent to certain parties, they will be requested to complete a "Consent to Use and Disclosure of Health Information" consent form, outlining specifically whom they do not information sent to and the time period involved.

Principle 4: Limiting Collection of Personal Information

The Sioux Lookout Meno Ya Win Health Centre limits the collection of personal information to that which is necessary to deliver the purposes outlined in Principle #2 of this policy. The personal information will be collected by fair and lawful means.

Principle 5: Limiting Use, Disclosure, and Retention of Personal Information

The SLMHC assures patients that personal information will not be used or disclosed for purposes other than those for which it was collected, except with the consent of the patient 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, the SLMHC will document this purpose and make public notice of the new purpose.
  • The SLMHC has guidelines and procedures with respect to the retention of personal information (see policy entitled "Retention of Health Records"). This policy includes minimum and maximum retention periods. The SLMHC is subject to legislative requirements with respect to retention periods.
  • Personal information that is no longer required to fulfill the identified purposes may be destroyed, as per the SLMHC policy entitled "Destruction of Patient Health Records".

Principle 6: 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 patient. 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.
  • The Sioux Lookout Meno Ya Win Health Centre will routinely update personal information when patient's present for treatment.
  • 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.

Principle 7: Ensuring Safeguards for Personal Information

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

  • The SLMHC will protect personal information regardless of the format in which it is held. The security safeguards will protect personal information against loss or theft, as well as unauthorized access, disclosure, copying, use, or modification.
  • The methods of protection include:
    1. Physical measures, for example, locked filing cabinets, lock down of computers when not in use, restricted access to offices, key-punch access to sensitive areas;
    2. Organizational measures, for example, limiting access on a "need-to-know" basis, and
    3. Technological measures, for example, the use of passwords, encryption, and user trail audits.
  • SLMHC will make its employees aware of the importance of maintaining the confidentiality of personal information. As a condition of employment, all new SLMHC employees/agents (e.g., employee, clinician, physician, allied health, volunteer, researcher, student, consultant, vendor, or contractor) must sign the SLMHC Confidentiality Agreement.
  • Care will be used in the disposal or destruction of personal information, to prevent unauthorized parties from gaining access to the information, please refer to the procedure outlined in the SLMHC policy entitled “Destruction of Health Records”.

Principle 8: Openness Regarding Personal Information Policies and Practices

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

  • The SLMHC policies and practices with respect to the management of personal information are readily available to patients if requested. Patients 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. If the need arises, interpreter services are available to patients.
  • The information made available includes:
    1. The name or title, and the address, of the Privacy Officer, who is accountable for SLMHC's privacy policies and practices, and to whom complaints or inquiries can be forwarded;
    2. The means of gaining access to personal information held by SLMHC;
    3. A description of the type of personal information held by SLMHC, including a general account of its use
    4. A copy of the patient brochure entitled "Privacy at Sioux Lookout Meno Ya Win Health Centre"
    5. What personal information is made available to related organizations.

Principle 9: Individual Access to Own Personal Information

The Sioux Lookout Meno Ya Win Health Centre will, upon request, inform a patient of the existence, use, and disclosure of his or her personal information and will provide access to that information. A patient will be able to challenge the accuracy and completeness of the information and have it amended as appropriate.

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

  • Upon request, SLMHC will inform a patient whether or not it holds personal information about the patient. The SLMHC will seek to indicate the source of this information and will allow the patient access to this information. However, it may choose to make sensitive medical information available through a medical practitioner. In addition, SLMHC will provide an account of the third parties to which it has been disclosed.
  • The SLMHC will respond to an individual's request within the time period outlined in the SLMHC policy entitled "Patient Access to Health Records - Process".
  • When a patient successfully demonstrates the inaccuracy or incompleteness of personal information, SLMHC 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 patient, the SLMHC 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.

Principle 10: Challenging Compliance with SLMHC's Privacy Policies and Practices

A patient will be able to address a challenge concerning compliance with this policy to the SLMHC Privacy Officer.

  • The SLMHC will investigate all complaints. If a complaint is found to be justified, SLMHC will take appropriate measures, including, if necessary, amending its policies and practices.