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Freeman Regional Health Services

Notice of Privacy Practices

Effective Date: March 13, 2003

Approved By: FRHS HIPAA Committee

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This Notice Describes How Your Medical Information 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 facility Privacy Officer by dialing 605-925-4000.

Each time you visit a hospital/long term care facility, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment, and billing related information. This notice applies to all the records of your care generated by the hospital/long term care facility whether made by hospital/long term care facility personnel, agents of the hospital/long term care facility, 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.

Our Responsibilities

Freeman Regional Health Services (FRHS) is required under the Health Insurance Portability & Accountability Act (HIPAA) of 1996 to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

Uses and Disclosures

How we may use and disclose medical information about you.

The following categories describe examples of the way we use and disclose medical information:

For treatment: We may use medical information about you to provide you treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital/long term care personnel who are involved in taking care of you at FRHS. For example: a doctor treating you for an injury may need to know if you have diabetes, because diabetes may slow the healing process, or if your Doctor orders Physical Therapy, the nursing staff will need to discuss your care and treatment with the Physical Therapist. Different departments of FRHS also may share medical information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals and x-rays.

Directory: We may include certain limited information about you in the facility directory while you are here. The information may include your name, location in the facility, your general condition (e.g. fair, stable, etc,) and your religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the facility directory, please request the Opt Out Form from the nursing staff or facility Privacy Officer.

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 disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.

Future Communications: We may communicate to you via newsletter, mail outs, or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our facility is participating in.

Organized Health Care Arrangement: This facility and its medical staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment, and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.

Affiliated Covered Entity: Protected health information will be made available to your physician as necessary to carry out treatment, payment, and health care operations.

As Required by Law:

Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

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

Law Enforcement: We may disclose health information for law enforcement purposes as required by law, or in response to a valid subpoena.

Federal Law makes provision for your health information to be released to an appropriate oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the Right to:

· Inspect and Copy: You have the right to inspect and receive a copy of the 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. 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. The organization’s HIPAA committee will provide a secondary review of all initial denials upon the request of the patient/resident. FCHNH will comply with the outcome of the review.

· 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 our facility. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

· An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of the disclosures we make of medical information about you. An accounting of disclosure prior to April 14, 2003, are not available.

· Request Restrictions: You have the right to request a restriction or limitations 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 payment for 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.

· Request Confidential Communications: You have the right to request that we communicate about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes.

· 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.

You may also obtain a copy of this notice at our website at www.FRHS.com

To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice at any time. The revised notice will be effective for information we currently have about you as well as any information we may obtain from you in the future. The current notice will be posted in the hospital and include the effective date. In addition, each time you register at or are admitted to FRHS for treatment or health care services, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the hospital by calling 605-925-4000 and asking for the facility Privacy Officer. You may also file a complaint with the Secretary of the Department of Health and Human Services. 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 the care that we provided you.

PRIVACY OFFICER:

Name: Dan Gran, CEO or Donna Brosz,, D.O.N.

Telephone Number: 605-925-4000