Notice of Privacy Practices

Effective Date:
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

If you have any questions about this notice, please contact the Privacy Official at (574) 546-8145.

WHO WILL FOLLOW THIS NOTICE:

This notice describes our hospital's practices and that of:

Our Responsibilities

We are committed to protecting medical information about you. We create a record of the care and services you receive at the hospital. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing related information. 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 by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.

This notice will tell your about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information.

For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people who may be involved in your medical care after you leave the hospital such as your physician or a subsequent healthcare provider, family members, clergy,

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 collected from you, your insurance company or a third party. For example, we may need to give your health plan information about the surgery you received at the hospital so your insurance company will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover it.

For Health Care 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. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services the hospital should offer. We may disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. We may combine the medical information we have with medical information from other hospitals to see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information to protect your privacy.

Appointment Reminders: We may use and disclose medical information to remind you that you have an appointment for treatment or medical care.

Follow Up Service: We may call you at home after your release to see if there are any problems.

Treatment Alternatives: We may use and disclose medical information to tell you about possible treatment alternatives.

Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services.

Patient Questionnaires: We may use and disclose medical information to assess your satisfaction with our services

Business Associates: We may use or disclose medical information about you to business associates we have contracted with to perform the agreed upon service and billing for it.

Some services are provided to the hospital by Business Associates. Some of these services include physician services in the emergency department and radiology, certain laboratory tests. The Business Associate is required to safeguard your information.

Fundraising Activities: We may use medical information about you to contact you in an effort to raise money for the hospital and its operations. We may disclose medical information to a foundation related to the hospital so that they may contact you in raising money for the hospital. We would only release information such as your name, address, phone number, and the dates you received treatment or services. If you do not want to be contacted for fundraising efforts, you must notify the hospital in writing.

Media: We may release medical information about you to the media only if authorized in writing by the patient or the patient's representative. The hospital is limited to providing only the facility directory information.

Future Communications: We may communicate to you via newsletters, or other means about health related information, disease-management programs, wellness programs, or other community activities the hospital are participating in.

Hospital Directory: We may include certain limited information about you in the hospital directory while you are a patient in the hospital. This information may include your name, location in the hospital, your general condition (e.g. good, fair, serious, critical) and your religious affiliation. This information may be provided to the clergy, and except for religious affiliation, to other people who ask for you by name. If you do not want to be listed in the hospital directory, you must notify, in writing the Admissions Staff or the Privacy Official.

Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Research: We may use and disclose information about you for research purposes. This process includes evaluation of the research proposal and approval by the review board who has established protocols to protect the privacy of your health information. We will almost always ask for your permission if the researcher will have access to your name, address or other information that reveals who you are.

To Avert a Serious Threat to Health or Safety: We may use or disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

As Required By Law: We will disclose medical information about you when required to do so by federal, state, or local law to the following types of entities including but not limited to:

Food and Drug Administration

Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability.

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court, administrative order, subpoena discovery request or other lawful process but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release medical information to a law enforcement official for purposes as required by law or in response to a valid subpoena.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:

Right to Inspect and 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 to the Health Information Services Department. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care 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 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

To request an amendment, your request must be made in writing and submitted to the Health Information Services Department. In addition, you must provide a reason that supports your request. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

Right to An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of the disclosures we made of medical information about you.
Disclosure for the purposes of treatment, payment, or healthcare operations are excluded.

To request this list or accounting of disclosures, you must submit your request in writing to the Health Information Services Department. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list.

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 health care 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 of your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

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 emergency treatment.

To request restrictions, you must make your request in writing to Registration at the time of admission or to the Health Information Services Department.

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. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Health Information Services Department. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

Please contact the Privacy Officer to obtain a written copy of this notice.

CHANGES TO THIS NOTICE

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, contact the Privacy Officer. All complaints must be submitted in writing.

You will not be penalized for filing a complaint

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 your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of care that we provided to you.

This Notice is effective 3/31/2003 and is available on request to any member of the public.

PRIVACY OFFICIAL
Name: Cheryl Ervin
Telephone Number: (574) 546-8145