CLARK MEMORIAL HOSPITAL
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE: April 14, 2003

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 Clark Memorial Privacy Officer by dialing 812.283.2626.

Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all the records of your care generated by the hospital, whether made by hospital personnel, agents of the hospital, or your personal doctor. Your personal doctor may have different policies or notices regarding his or her uses and disclosures of our medical information created in the doctor’ office or clinic.

OUR RESPONSIBILITY

We are required by law and by our own standards to maintain the privacy of your health information and provide you with a description of our privacy practices. We will abide by the terms of this notice.

USES AND DISCLOSURES

How we may use and disclose medical information about you.

FOR TREATMENT: We may use your medical information to provide you treatment or services. We may disclose your medical information 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. Different departments of the hospital also may share your medical information in order to coordinate the different things you may need, such as prescriptions, lab work, meals and x-rays. We may also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you are discharged from Clark Memorial. FOR

PAYMENT: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example: we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it. FOR

HEALTH CARE OPERATIONS: Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. For example: we may combine medical information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses and other students for education purposes. And we may combine medical information we have with that of other hospitals to see where we can make improvements. We may remove information that identifies you from this set of medical information to protect your privacy.

We may also use and disclose medical information:

  • To business associates we have contracted with to perform the agreed upon service and billing for it;
  • To remind you that you have an appointment for medical care;
  • To assess your satisfaction with our services;
  • To tell you about possible treatment alternatives;
  • To tell you about health-related benefits or services;
  • To contact you as part of fundraising efforts for the hospital foundation;
  • To inform Funeral Directors consistent with applicable law;
  • For population based activities relating to improving health or reducing health care costs; and
  • For conducting training programs or reviewing competence of health care professionals.

BUSINESS ASSOCIATES: There are some services provided in our organization through contracts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

DIRECTORY: We may include certain limited information about you in the hospital directory while you a patient at Clark Memorial. The information may include your name, location in the hospital, your general condition (i.e. good, fair, 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. You will have the option to Opt Out (decline) of being in the Clark Memorial Hospital directory while you are an inpatient.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE: We may disclose to your family, a relative, a close friend or any other person you identify as your emergency contact(s), your health information that relates to that person’s involvement in your care or payment related to your care. In addition, we may disclose your medical information 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 after an institutional review board has reviewed the research proposal and the established protocols to ensure the privacy of your health information has approved their research.

FUTURE COMMUNICATION: We may communicate to you via newsletters, direct mail 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 in their offices to protected health information to assist in reviewing past treatment as it may affect treatment at the time.

AS REQUIRED BY LAW, we also may use and disclose health information for 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
  • Correctional institutions
  • Workers compensation agents
  • Organ and tissue donation organizations
  • Military command authorities
  • Health oversight agencies
  • Funeral directors, coroners and medical directors
  • National security and intelligence agencies
  • Protective services for the President of the United States and others.

LAW ENFORCEMENT/LEGAL PROCEEDINGS: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.

STATE SPECIFIC REQUIREMENTS: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs. Some states have separate privacy laws that may apply additional legal requirements. If the State privacy laws are more stringent than Federal privacy laws, the State law preempts the Federal law.

YOUR HEALTH INFORMATION RIGHTS Although your health record is the physical property of the health care practitioner or facility that compiled it, you have the RIGHT to:

  • INSPECT & RECEIVE COPY: You have the right to inspect and have copied protected health information that is in a designated record set and may be used to make decisions about your care after completion of appropriate forms. Usually, this includes medical and billing records, but does not include psychotherapy notes, information compiled in reasonable anticipation of, or use in a civil, criminal or administrative action or proceedings. We may deny your request to inspect and have copied certain protected health information. If you are denied access to medical information, you may request that denial be reviewed. Another licensed health care professional chosen by Clark Memorial 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.
  • AMEND: If you feel that your medical information is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment in writing for as long as the information is kept by or for Clark Memorial. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial. To request an amendment, your request must be made in writing and submitted to our Privacy Officer.
  • AN ACCOUNTING OF DISCLOSURES: You have a right to request an accounting of disclosures of your health information. This is a list of certain disclosures we make of your medical information for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices.
  • REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the medial 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 in the 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 required to notify you if we are unable to agree to a requested restriction.
  • 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 may ask that we contact you at work or by U.S. Mail. The facility will grant requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address. This address must be where the individual will receive bills for service rendered by the facility, and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
  • A PAPER COPY OF THIS NOTICE: You have a 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. o You may obtain a copy of this notice at our web site: § www.clarkmemorial.org 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. The revised or changed notice will be effective for information we already have about you as well as any information we receive 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 admitted to the hospital for treatment or health care services as an inpatient or outpatient, 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 Privacy Officer and with the Secretary of the U.S. Department of Health and Human Services by sending correspondence to: Clark Memorial Hospital Director of HIM/Privacy Officer 1220 Missouri Avenue Jeffersonville, IN 47130 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 Indiana law 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 to you.

Clark Memorial Hospital Privacy Officer 812.283.2626

About Us • Vital Stats • Services • Emergency
Staff • Calendar • Contacts • News
Births • Gift Shop • Careers • Links
HOME