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.
Purpose of This Notice
This notice tells you about how we use and disclose your medical information. It tells you about your rights and our responsibilities to protect the privacy of your medical information. It also tells you how to complain to us, or the government if you believe that we have violated any of your rights or any of our responsibilities.
We are required by law to maintain the privacy of your medical information. We must provide you with a copy of this notice and get your written acknowledgement of its receipt. We must follow the terms of this notice that are currently in effect.
We will tell you if we change this notice. A copy of the revised notice will be available upon request or posted at our location or on our website. We may change our practices and those changes may apply to medical information we already have about you as well as any new information.
This notice will be given to you on the date that you first receive medical products or treatment from Sarah D. Culbertson Memorial Hospital. In an emergency, we will give you the notice as soon as possible after the emergency treatment has been given.
How We Use or Disclose Your Medical Information
We will use the medical information about you to provide you with treatment and services. We may share this information with members of our healthcare staff or with others involved in your care such as doctors, nurses, or health care facilities. For example, a nurse who is involved in your care will report any changes in your condition to your doctor. We may also disclose your health information to a member of your family or other person who is involved in your care.
We may use or disclose your medical information to bill and collect payment for the services we provided to you. For example, we may need to give your health insurance plan information about your diagnosis, treatment and supplies used. We may also contact your insurance plan to confirm your coverage or to request prior approval for a planned treatment or service.
Health Care Operations
We may use or disclose your medical information for operational purposes. For example, we may use your medical information to evaluate our services, including the performance of our staff in caring for you. We may also use this information to learn how to continually improve the quality and effectiveness of the health care services that we provide to you.
Common Disclosures for Treatment, Payment or Health Care Operations
Your name and address may be used to send out patient satisfaction surveys.
We may contact you either by telephone or by mail at Sarah D. Culbertson Memorial Hospital, your home or your office to remind you of an appointment that you have with us or any other matter related to the health care services we provide or payment for your health care services. We may leave messages for you. If you want us to contact you in a certain way or at a certain location, see “Right to Receive Confidential Communications” in this notice.
There are some services that are provided for us by our business associates such as accountants, consultants and attorneys. Whenever we share information with our business associates we will have a written contract with them that requires that they protect the privacy of your medical information.
Other Use and Disclosures of Your Medical Information
Fund-raising --Your name and address and the dates you received treatment or services may be added to a mailing list of patients in order to invite you to a fund-raising event or to send you a newsletter. If you do not want to receive these communications, please notify Our Designee in writing.
Treatment Alternatives --We may use and disclose medical information about you to contact you about other health care treatment that is available to you. If you do not want to receive these communications, please notify Our Designee in writing.
Health Related Benefits and Services --We may use and disclose medical information about you to contact you about other health care benefits or services that may interest you. If you do not want to receive these communications, please notify Our Designee in writing.
Individuals Involved in Your Care --We may disclose medical information about you to a family member, other relative, close friend or any other person identified by you if they are involved in your care or payments related to your care. We may also use or disclose medical information about you to notify those persons of your location, general condition or death. If there is a family member, other relative or close friend to whom you do not want us to disclose medical information about you, please notify Our Designee in writing.
Patient Directory --Your name, room number, and your medical condition described in general terms will be listed in our directory. This directory will be used when visitors ask for you by name. We will also list your religious affiliation in the directory. Your religious affiliation will only be given to members of the clergy who ask for this information. If you do not want to be included in our directory, or you wish to reduce the information we include in the directory you must notify Our Designee of your objection.
Use or Disclosures That Are Required or Permitted by Law
Disaster Relief --We may use or disclose medical information about you to assist in disaster relief efforts. This will be done to notify family members or others of your location, general condition or death in the event of a natural or man-made disaster.
Required by Law --We may use or disclose medical information about you when we are required to do so by law.
Communicable Diseases --We may disclose your medical information to a person who may have been exposes to an infectious disease or who is at risk of spreading the disease or condition.
Public Health Activities --We may disclose medical information about you for public health activities to prevent or control disease.
Victims of Abuse, Neglect or Domestic Violence --We may disclose medical information about you to a government agency if we believe you are a victim of abuse, neglect or domestic violence.
Health Oversight Activities --We may disclose medical information about you to a health oversight agency.
Food and Drug Administration --We may disclose medical information about you to monitor drugs or devises controlled by the Food and Drug Administration.
We may disclose medical information about you in response to a court proceeding. We may also disclose medical information about you in response to a subpoena or other legal process.
Disclosures for Law Enforcement Purposes --We may disclose information about you to law enforcement officials for law enforcement purposes:
- As required by law.
- In response to a court order or other legal proceeding.
- To identify or locate a suspect, fugitive, material witness or missing person.
- When information is requested about an actual or suspected victim of a crime.
- To report a death as a result of possible criminal conduct.
- About crimes that occur on our premises.
- To report a crime in emergency circumstances.
Funeral Directors, Coroners and Medical Examiners --We may disclose medical information about you as necessary to allow these individuals to carry our their responsibilities.
Organ Donation --We may disclose medical information about you to organ procurement organizations if you are an organ donor.
Workers’ Compensation --We may disclose medical information about you to comply with workers’ compensation laws that provide benefits for work-related injuries or illnesses.
Public Health or Safety --We may use or disclose medical information about you if we believe it is necessary to prevent a threat to the health or safety of a person or the general public.
Military --If you are a member of the Armed Forces, we may disclose medical information about you to your military command.
National Security and Intelligence --We may disclose medical information about you to authorize federal officials for national security and intelligence activities.
Security Clearance --We may use medical information about you for a required security clearance.
Inmates --We may disclose medical information about you to a correctional institution or law enforcement official who has custody of you.
Research --We may disclose your medical information to researchers under certain limited circumstances.
Uses or Disclosures That Require Your Authorization
Other uses and disclosures will be made only with your written authorization. You may cancel and authorization at any time by notifying Our Designee in writing of your desire to cancel it. If you cancel an authorization it will not have any affect on information that we have already disclosed. Examples of uses or disclosures that may require your written authorization include the following:
- A request to provide certain medical information to a drug company for marketing purposes.
- A request to provide your medical information to an attorney for use in a civil law suit.
The information contained in your health or medical records is the physical property of Sarah D. Culbertson Memorial Hospital. The information in it belongs to you. You have the following rights:
Right to Request Restrictions --You have the right to ask us not to use or disclose your medical information for a particular reason related to treatment, payment or our operations. You may ask that family members or other individuals not be informed of specific medical information. That request must be made in writing to Our Designee. We do not have to agree to your request. If we agree to your request, we must keep the agreement, except in the case of a medical emergency. Either you or Sarah D. Culbertson Memorial Hospital can stop a restriction at any time.
Right to Receive Confidential Communications --You have the right to ask that we communicate with you in a certain manner or at a certain place. If you want to request confidential communications the request must be made in writing to Our Designee. We must agree to your request if it is reasonable.
Right to Inspect and Copy Your Medical Information --You have the right to request to inspect and obtain a copy of your medical information. You must submit your request in writing to Our Designee. If you request a copy of the information or that we provide you with a summary of the information we may charge a fee for the costs of copying, summarizing and/or mailing it to you.
If we agree to your request we will tell you. We may deny your request under certain limited circumstances. If your request is denied, we will let you know in writing and you may be able to request a review of our denial.
Right to Request Amendments to Your Medical Information --You have the right to request that we correct your medical information. If you believe that any medical information in your record is incorrect or that important information is missing, you must submit your request for an amendment in writing to Our Designee.
We do not have to agree to your request. If we deny your request we will tell you why. You have the right to submit a statement disagreeing with our decision. We may deny your request if we determine that the information:
- Was Not created by us
- Is not part of the medical information that we maintain
- Is in records that you are not allowed to inspect and copy
- Is already accurate or complete
Right To An Accounting of Disclosures of Health Information --You have the right to find out what disclosures of your medical information have been made. The list of disclosures is called an accounting. The accounting may be for up to six (6) years prior to the date on which you request the accounting, but can not include the disclosures before April 14, 2003.
We are not required to include disclosures for treatment, payment or healthcare operations or certain other exceptions. Requests for an accounting of disclosures must be submitted in writing to Our Designee. You are entitled to one free accounting in any twelve (12) month period. We may charge you for the cost of providing additional accountings. If there will be a charge we will notify you in advance.
Right To Obtain a Copy of the Notice --You have the right to request and get a paper copy of this notice and any revisions we make to the notice at any time.
You have the right to complain to us and to the United States Secretary of Health and Human Services if you believe we have violated your privacy rights. There is no risk in filing a complaint.
To file a complaint with us, contact by phone or by mail:
238 S. Congress Rushville, Illinois 62681
PH# (217) 322-4321
FAX# (217) 322-4246
To file a complaint with the United States Secretary of Health and Human Services send your complaint to him or her in care of:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Questions and Information
If you have any questions or want more information about this Notice of Privacy Practices, please contact:
238 S. Congress Rushville, Illinois 6268
By phone with questions or with written requests for information as defined under the Your Rights section of this notice. Complaints or questions may be made by phone or in writing.