GOTHENBURG MEMORIAL HOSPITAL

NOTICE OF PRIVACY PRACTICES

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.

WHO WILL FOLLOW THIS NOTICE:

• Any health care professional authorized to enter information into your medical record
• All departments of Gothenburg Memorial Hospital including Long Term Care
• Any member of a volunteer group or health care students we allow to help you while you are receiving care at this facility
• All employees including those under contract
• Your physician may have different policies or notices regarding the physician’s use and disclosure of your medical information created in the physician’s clinic.

OUR PLEDGE REGARDING MEDICAL INFORMATION:

We understand that information about you and your health is personal and we will make every attempt to protect that information. We create a record of the care and services you receive each time you have any type of treatment. This record assists us in providing quality care and meets legal requirements. The Privacy Notice covers all records of your care provided at Gothenburg Memorial Hospital.

This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and our responsibilities regarding the use and disclosure of your medical information.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:

Although your medical record is the physical property of Gothenburg Memorial Hospital, the information belongs to you. Gothenburg Memorial Hospital has developed procedures as described in the federal law that allow you several rights.

Right to see and get copies of your medical information

In most cases, you have the right to look at or get copies of your medical information that we have, but you must make the request in writing. If we do not have your information but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you in writing our reasons for the denial and how you can have the denial reviewed. If you request copies of your medical information, we may charge a fee for the costs of the copying, mailing or other supplies associated with your request.

Right to Correct or Update Your Medical Information

If you believe that there is a mistake in your medical information or that a piece of the information is missing, you have the right to request that we correct the existing information or add the missing information. That request must be made in writing and you must provide a reason for the change. We will respond within 60 days of receiving your request. We may deny your request if it is not in writing or does not include a reason to support the request. Also we may deny your request if the medical information is:

• Correct and complete
• Not created by us
• Not allowed to be looked at and copied for you
• Not part of our records

Our written denial will tell you the reasons for the denial and will tell you how to file a written statement of disagreement with the denial.

Right to Get a List of the Disclosures We Have Made

You have the right to get a list of instances in which we have disclosed your medical information. This list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment or health care operations, directly to you or your family or in our facility directory. This list also will not include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or before the effective date of this notice. We will respond within 60 days of receiving your written request and will include disclosures made in the last six years, but not before the effective days of this notice, unless you request a shorter time. We will provide list to you at no charge, but if you make more than one request in the same year, there will be a charge for each additional request. We will notify you of the cost involved and you may choose to withdraw or change your request at that time.

Right to Request Limits on Uses and Disclosures of Your Medical Information

You have the right to ask that we limit how we use and disclose your medical information. We will consider your written request but are not legally required to accept it. If we accept your request, we will abide by it except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make.

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.

Right to Withdraw Your Authorization to Use or Disclose Your Medical Information

If you give us permission to use or disclose your medical information, you may withdraw or cancel that permission, in writing at any time. If you withdraw 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.

Right to Request Alternative Communications

You may request that your Protected Health Information be communicated by alternative means. For example, you may request that your bill be sent to another address, that we should or should not contact you at a specific telephone number and if you would prefer that messages not be left on an answering machine.

HOSPITAL RESPONSIBILITIES

· Maintain the privacy of your medical information

· Provide you with a paper copy of this notice

· Abide by the terms of this notice

· Notify you if we are unable to agree to a requested limit or restriction

· Follow reasonable requests you may have to communicate your medical information at an alternate address or by an alternate means.

We reserve the right to or may be required by law to change our privacy practices, which may result in changes in this notice. We further reserve the right to make the revised or changed privacy practices notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the notice in the hospital. The notice’s effective date will be noted on the last page of the document. In addition, each time you register or are admitted to the hospital for treatment or health care services, we will offer you a copy of the current notice in effect. We will not use or disclose your health information without your permission or authorization, except as described in this notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Not every use or disclosure in a category is listed, however all the ways we are permitted to use and disclose your medical information will fall within one of these categories.

· For Treatment – We may provide medical information about you to doctors, nurses, technicians, students and other personnel who may take care of you. In addition, information may be shared with personnel and facilities outside of Gothenburg Memorial Hospital. As an example, if you are transferred to another health care facility or referred for home health services, certain information will be shared with that facility to assist them in providing treatment to you. Also, x-rays taken here will be read by a radiologist who is on our consulting medical staff and certain lab tests may need to be sent to another facility.

· For Payment – A bill may be sent to you or a third-party payer such as Medicare, Medicaid, or private insurance. The information on or sent with the bill may include your identity, diagnosis, procedures performed and supplies used. In order to obtain approval or to determine whether your health plan will cover the treatment and hospital stay, we may tell them details regarding your diagnosis and treatment you are receiving while you are in the hospital.

• For Health Care Operations – We may use medical information about you for health care operations that help us to provide quality care. For example, we may use information in your record to review our treatment, services and the performance of our staff and to evaluate the need for additional services. We may provide this information to medical and healthcare students for learning purposes.

• As Required by Law – We will provide medical information about you when required to do so by federal, state or local laws.

• To Avert a Serious Threat to Health or Safety – Medical information about you may be used when needed to prevent a serious threat to your health and safety or the health and safety of others. The information will only be provided to someone able to help with the threat.

• Hospital Directory – Unless you notify us that you object, we will use your name, location in the facility and religious affiliation for directory purposes. This information may be provided to members of the clergy and to other people who ask for you by name.

• Communication with Family – We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location and general condition. Health care professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. Please notify hospital personnel if you have specific requests regarding our providing information to a family member

• Reminders and Follow-Up Calls – We will use your information for appropriate reminders i.e. to contact you regarding an appointment or other health-related benefits and services that may be of interest to you. We may also use your information to contact you following your treatment at the facility.

• Research – In certain circumstances, your information may be released for research providing the research process has been properly approved by the facility.

• Organ and Tissue Donation – If you are an organ donor, we may provide medical information to organizations that handle organs for organ, eye or tissue transplantation or to do an organ donation bank.

• Workers Compensation - We may provide information about you for workers compensation or similar programs that provide benefits for work-related injuries or illness.

• Public Health Activities – This may include release of information for the following:

ü To prevent or control disease, injury or disability

ü To report births or deaths

ü To report reactions to medications or problems with products

ü To notify people of recalls of products they may be using

ü To notify a person who may have been exposed to a disease or may be at risk for getting or spreading a disease or condition

ü To notify the government if we suspect a patient has been the victim of abuse, neglect or domestic violence. We will make this disclosure if you agree or when required or authorized by law.

· Health Oversight Activities – We may provide medical information to a health oversight agency for activities allowed by law. Oversight activities that allow the government to monitor the health care system, government programs and compliance with civil rights laws include audits, investigation, inspections and licensure.

· Laws and Disputes -- We may provide medical information about you in response to a court or administrative order. This information may be provided in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if we have tried to tell you about the request or to obtain an order protecting the information requested.

· Law Enforcement – We may provide medical information if asked to do so by a law enforcement official, examples being:

ü Response to a court order, subpoena, warrant, summons or similar process

ü To identify or locate a suspect, fugitive, material witness, or missing person

ü Inquiries as to the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement

ü To inquire as to a death we believe may be the result of criminal conduct

ü To inquire as to criminal conduct at the hospital

ü To report a crime, location of the crime or victims or the identity, description or location of the person who committed the crime

· Coroners, Medical Examiners and Funeral Directors – The hospital may provide medical information to a coroner or medical examiner. For example, to identify a person who has died or to determine the cause of death. We may also provide medical information about patients to funeral directors that need to carry out their duties.

· National Security and Intelligence Activities – We may provide medical information about you to federal officials for intelligence, counterintelligence, and other national security activities including for protection of the president and others or to conduct special investigations.

· Inmates – We may provide information about you to a correctional institution or law enforcement official if you are an inmate of a correctional institution or under the custody of law enforcement. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

· Fundraising – We may use your information for fundraising activities. For example, we may contact you in an effort to raise money for the hospital and its operations. The information may be released to a foundation related to the hospital so that they may contact you. We would only release your name, address, phone number and dates you received service at the hospital. If you do not want the hospital to contact you for such purposes you must notify Gothenburg Memorial Hospital Administrator in writing.

Business Associates

We may provide medical information to other persons or organizations, known as business associates, who provide services for the hospital. We require our business associates to protect the medical information we provide to them.

OTHER USES OF MEDICAL INFORMATION

Other uses of medical information not covered by this notice or the laws that apply to us will be made only if you agree in writing. If you give us the right to use medical information, you may change your mind at any time and submit this request in writing. If you change your mind, we will no longer use the medical information for the reasons covered by your written request. You understand that we cannot take back any information that we have already released with your written agreement and that we are required to retain records of the care we provide.

ORGANIZED HEALTH CARE ARRANGEMENT

Gothenburg Memorial Hospital staff and independent providers who belong to the Medical Staff must be able to share protected health information freely for treatment, payment and health care operations. Therefore, each eligible provider on the hospital’s medical staff has entered into an “Organized Health Care Arrangement” or OHCA. Under the OHCA, each provider will:

• Use a joint notice of privacy practices (this notice) for all inpatient and outpatient visits at the facility
• Obtain a single signed acknowledgement of receipt
• Share protected health information from inpatient and outpatient hospital visits with eligible providers
• Follow the privacy and information practices described in this Notice. Each OHCA participant is individually responsible to follow the practices in the Notice.

COMPLAINTS

If you feel your privacy rights have been violated, you may complain in writing to the Privacy Officer or the Health Information Manager at Gothenburg Memorial Hospital or to the Secretary of the Department of Health and Human Services or the Office of Civil Rights. You will not be penalized or otherwise retaliated against for filing a complaint.

Effective Date: April 14, 2003 Version # 1