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.

UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION:

Each time you visit a hospital, physician, or other healthcare provider, a record of your stay is made containing health and financial information. Typically, this record contains information about your condition, the treatment we provide and payment for the treatment. We may use and/or disclose this information for:

  • Basis for planning your care and treatment
  • Means of communication among the healthcare professionals who contribute to your care
  • Legal document describing the care you received
  • Means by which you or a third- party payer can verify that billed services were provided
  • Tool used in educating healthcare professionals
  • Source of data for medical research
  • Source of information for public health officials to use to improve the health of the nation
  • Source of data for facility planning and marketing
  • Tool for the hospital to use to assess and continually work to improve the care provided

Understanding what is in your record and how this information is used will help you to:

  • Ensure it is accurate
  • Better understand who, what, when, and why others may access your health information
  • Make more informed decisions when authorizing disclosure to others

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

Although your health record is the property of the Facility, the information belongs to you.  You have the following rights regarding your health information:

  • Right to Inspect and Copy: With some exceptions, you have the right to review and copy your health information.
  • Right to Amend:  If you feel that health information in your record is incorrect or incomplete, you may ask us to amend the information.  You have this right for as long as the information is kept by or for the Facility.
  • Right to an Accounting of Disclosures:  You have the right to request an “Accounting of Disclosures”.  This is a list of certain disclosures we made of your health information, other than those made for purposes such as treatment, payment, or health care operations.
  • Right to Request Restrictions:  You have the right to request a restriction or limitation on the health information we use or disclose about you.  For example, you may request that we limit the health information we disclose to someone who is involved in your care or the payment for your care. You could ask that we not use or disclose information about a surgery you had to a family member or friend.
  • Right to Request Alternate Communications:  You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location.  For example, you may ask that we only contact you via mail to a post office box.
  • Right to a Paper Copy of This Notice:  You have the right to a paper copy of this Notice of Privacy Practices even if you have agreed to receive the Notice electronically.  You may ask us to give you a copy of this Notice at any time.
  • Right to Revoke Your Authorization: You have the right to revoke your authorization to us or disclose your health information except to the extent that action has already been taken.
  • Right to Receive Breach Notifications: You have the right to receive notifications whenever a breach of your unsecured protected health information occurs.

HOSPITAL RESPONSIBILITES

This organization is required to:

  • Maintain the privacy of your health information
  • Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
  • Abide by the terms of this notice
  • Notify you if we are unable to agree to a requested restriction
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide a revised notice at the time of your next visit to the hospital for healthcare services.

We will not use or disclose your health information without your authorization, except as described in this notice.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe the ways that we use and disclose health information. Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall into one of the three categories.

  1. For Treatment: To provide, coordinate, or manage your health care and related services. Examples: Coordinating future care with a nursing facility, a home health agency, another hospital, an outside laboratory, or another physician who becomes involved in your care (at request of your physician) by providing assistance with your diagnosis and/or treatment.
  2. For Payment: To obtain payment for your healthcare services by your health insurance plan or from another individual or organization responsible for that payment. Examples: determining insurance benefits, reviewing planned services for medical necessity, completing utilization review activities required by your insurance plan, and sending a claim for payment.
  3. For Health Care Operations.  To complete activities as required by the standards of the hospitals’ accreditation organization, federal regulations and Indiana Law.
  • Facility Directory.  We may include information about you in the Facility directory while you are a resident.  This information may include your name, location in the Facility, your general condition (e.g., fair, stable, etc.) and your religion.  The directory information, except for your religion, may be disclosed to people who ask for you by name.  Your religion may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name.  This is so your family, friends and clergy can visit you in the Facility and generally know how you are doing.
  • Individuals Involved in Your Care or Payment for Your Care.  Unless you object, we may disclose health information about you to a friend or family member who is involved in your care.  We may also give information to someone who helps pay for your care.  In addition, we may disclose health 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.
  • Quality of Care. Medical Staff members, hospital managers and designated staff and the Board of Trustees may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the hospitals healthcare services.
  • Business Associates. There are some services provided in our Facility through contracts with business associates. Examples include processing of certain laboratory tests in an outside laboratory, coding of health information by an outside service, submission of data to the Indiana Health and Hospital Association for benchmarking with other hospitals.
  • Coroners, Medical Examiners and Funeral Directors.  We may disclose medical information to a coroner or medical examiner.  This may be necessary to identify a deceased person or determine the cause of death.  We may also disclose medical information to funeral directors as necessary to carry out their duties.
  • Organ and Tissue Donation.  If you are an organ donor, we may disclose health information to organizations that handle organ procurement to facilitate donation and transplantation.
  • Research.  Under certain circumstances, we may use and disclose health information about you for research purposes.  For example, a research project may involve comparing the health and recovery of all residents who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of health information, trying to balance the research needs with residents’ need for privacy of their health information.  Before we use or disclose health information for research, the project will have been approved through this research approval process.
  • Workers’ Compensation.  We may disclose health information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.
  • Reporting. Federal and state laws may require or permit the Facility to disclose certain health information related to the following:
    • Public Health Risks.  We may disclose health information about you for public health purposes, including:
      • Prevention or control of disease, injury or disability
      • Reporting births and deaths;
      • Reporting reactions to medications or problems with products;
      • Notifying people of recalls of products;
      • Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease;
      • Notifying the appropriate government authority if we believe a resident has been the victim of abuse, neglect or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.
      • Health Oversight Activities.  We may disclose health information to a health oversight agency for activities authorized by law.  These oversight activities may include audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
      • Judicial and Administrative Proceedings:  If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order.  We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
      • Reporting Abuse, Neglect or Domestic Violence:  Notifying the appropriate government agency if we believe a resident has been the victim of abuse, neglect or domestic violence.

•    Law Enforcement.  We may disclose health information when requested by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at the Facility; and
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

•    Correctional Institution:  Should you be an inmate of a correctional institution, we may disclose to the institution or its agents health information necessary for your health and the health and safety of others.

•    Fundraising Activities.  We may use health information about you to contact you in an effort to raise money as part of a fundraising effort.  We may disclose health information to a foundation related to the Facility so that the foundation may contact you in raising money for the Facility.  We will only release contact information, such as your name, address and phone number and the dates you received treatment or services at the Facility. You have the right to opt out of receiving these fundraising communications.

•    As Required By Law.  We will disclose health information about you when required to do so by federal, state or local law.

•    Military and Veterans.  If you are a member of the armed forces, we may disclose health information about you as required by military authorities.  We may also disclose health information about foreign military personnel to the appropriate foreign military authority.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us, including disclosure of protected health information for marketing purposes and disclosures that constitute the sale of protected health information; will be made only with your written permission.  If you provide us permission to use or disclose health 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 health 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 the care that we provided to you.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice.  We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future.  We will post a copy of the current Notice in the Facility and on the website.  The Notice will specify the effective date on the first page, in the top right-hand corner.  In addition, if material changes are made to this Notice, the Notice will contain an effective date for the revisions and copies can be obtained by contacting the Facility administrator.

FOR MORE INFORMATION: If you have any questions or would like additional information, you may contact the Hospital’s Privacy Officer at (765) 658-2717.

TO REPORT A PROBLEM:  If you believe your privacy rights have been violated, or if you disagree with a decision we made about access to or amendments to your health records, you may file a complaint with the hospital’s Privacy Officer or you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Under no circumstances will you be penalized or suffer retaliation for filing a complaint.

FOR ACCESS TO YOUR HEALTH RECORD:  
To inspect or receive a copy of your health record, call the Medical Records Department at (765)655-2590 to make arrangements to do so during regular business hours (8:00a-4:00p).

Revised: September 20, 2013

Effective Date: September 20, 2013