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.

Protected Health Information

Information about your health is private. And it should remain private. That is why this healthcare institution is required by federal and state law to protect the privacy of your health information. We call it "Protected Health Information" (PHI). Staff members, employees and volunteers of this hospital/facility must follow legal regulations with respect to:

• How We Use Your PHI
• Disclosing Your PHI to Others
• Your Privacy Rights
• Our Privacy Duties
• Hospital Contacts for More Information or, if necessary, a Complaint

Using or Disclosing Your Phi for Treatment

During the course of your treatment, we use and disclose your PHI. For example, if we test your blood in our laboratory, a technician will share the report with your doctor. Or, we will use your PHI to follow the doctor’s orders for an x-ray, surgical procedure or other types of treatment related procedures.

For Payment

After providing treatment, we will ask your insurer to pay us. Some of your PHI may be entered into our computers in order to send a claim to your insurer. This may include a description of your health problem, the treatment we provided and your membership number in your employer’s health plan.

Or, your insurer may want to review your medical record to determine whether your care was necessary. Also, we may disclose to a collection agency some of your PHI for collecting a bill that you have not paid.

For Healthcare Operations

Your medical record and PHI could be used in periodic assessments by physicians about the hospital’s quality of care. Or we might use the PHI from real patients in education sessions with medical students training in our hospital. Other uses of your PHI may include business planning for our hospital or the resolution of a complaint.

Special Uses

Your relationship to us as a patient might require using or disclosing your PHI in order to

• Remind you of an appointment for treatment
• Tell you about treatment alternatives and options
• Tell you about our other health benefits and services

Your Authorization May Be Required In many cases, we may use or disclose your PHI, as summarized above, for treatment, payment or healthcare operations or as required or permitted by law. In other cases, we must ask for your written authorization with specific instructions and limits on our use or disclosure of your PHI. You may revoke your authorization if you change your mind later.

Certain Uses and Disclosures of Your Phi Required or Permitted By Law

As a hospital or healthcare facility, we must abide by many laws and regulations that either require us or permit us to use or disclose your PHI.

Required or Permitted Uses and Disclosures

• Your information may be included in a patient directory that is available only to those individuals whom you have identified as contacts during your hospital stay. You will receive a unique patient code that can be provided to these contacts.
• We may use your PHI in an emergency when you are not able to express yourself.
• We may use or disclose your PHI for research if we receive certain assurances which protect your privacy.

We may also use or disclose your PHI

• When required by law, for example when ordered by a court.
• For public health activities including reporting a communicable disease or adverse drug reaction to the Food and Drug Administration.
• To report neglect, abuse or domestic violence.
• To government regulators or agents to determine compliance with applicable rules and regulations.
• In judicial or administrative proceedings as in response to a valid subpoena.
• To a coroner for purposes of identifying a deceased person or determining cause of death, or to a funeral director for making funeral arrangements.
• For purposes of research when a research oversight committee, called an institutional review board, has determined that there is a minimal risk to the privacy of your PHI.
• For creating special types of health information that eliminate all legally required identifying information or information that would directly identify the subject of the information.
• In accordance with the legal requirements of a workers compensation program.
• When properly requested by law enforcement officials, for instance in reporting gun shot wounds, reporting a suspicious death or for other legal requirements.
• If we reasonably believe that use or disclosure will avert a health hazard or to respond to a threat to public safety including an imminent crime against another person.
• For national security purposes including to the Secret Service or if you are Armed Forces personnel and it is deemed necessary by appropriate military command authorities.
• In connection with certain types of organ donor programs.

Your Privacy Rights and How to Exercise Them

Under the federally required privacy program, patients have specific rights.

Your Right to Request Limited Use or Disclosure

You have the right to request that we do not use or disclose your PHI in a particular way. However, we are not required to abide by your request. If we do agree to your request, we must abide by the agreement.

Your Right to Confidential Communication

You have the right to receive confidential communication from the hospital at a location that you provide. Your request must be in writing, provide us with the other address and explain if the request will interfere with your method of payment.

Your Right to Revoke Your Authorization

You may revoke, in writing, the authorization you granted us for use or disclosure of your PHI. However, if we have relied on your consent or authorization, we may use or disclose your PHI up to the time you revoke your consent.

Your Right to Inspect and Copy

You have the right to inspect and copy your PHI. We may refuse to give you access to your PHI if we think it may cause you harm, but we must explain why and provide you with someone to contact for a review of our refusal.

Your Right to Amend Your PHI

If you disagree with your PHI within our records, you have the right to request, in writing, that we amend your PHI when it is a record that we created or have maintained for us. We may refuse to make the amendment and you have a right to disagree in writing. If we still disagree, we may prepare a counter-statement. Your statement and our counter-statement must be made part of our record about you.

Your Right to Know Who Else Sees Your PHI

You have the right to request an accounting of certain disclosures we have made of your PHI over the past six years, but not before April 14, 2003. We are not required to account for all disclosures, including those made to you, authorized by you or those involving treatment, payment and healthcare operations as described above. There is no charge for an annual accounting, but there may be charges for additional accountings. We will inform you if there is a charge and you have the right to withdraw your request, or pay to proceed.

What If I Have a Complaint?

If you believe that your privacy has been violated, you may file a complaint with us or with the Secretary of Health and Human Services in Washington, D.C. We will not retaliate or penalize you for filing a complaint with the facility or the Secretary.

To file a complaint with us, please contact the hospital’s Risk Management Department or call the UHS Compliance Hotline at 1-800-852-3449. Your complaint should provide specific details to help us in investigating a potential problem.

To file a complaint with the Secretary of Health and Human Services, write to: 200 Independence Ave., S.E., Washington, D.C. 20201 or call 1-877-696-6775.

Some of Our Privacy Obligations and How We Fulfill Them

Federal health information privacy rules require us to give you notice of our privacy practices. This document is our notice. We will abide by the privacy practices set forth in this notice. However, we reserve the right to change this notice and our privacy practices when permitted or as required by law.

If we change our notice of privacy practices, we will provide our revised notice to you when you next seek treatment from us.

Compliance with Certain State Laws

When we use or disclose your PHI as described in this notice, or when you exercise certain of your rights set forth in this notice, we may apply state laws about the confidentiality of health information in place of federal privacy regulations. We do this when these state laws provide you with greater rights or protection for your PHI. For example, some state laws dealing with mental health records may require your express consent before your PHI could be disclosed in response to a subpoena. Another state law prohibits us from disclosing a copy of your record to you until you have been discharged from our hospital. When state laws are not in conflict or if these laws do not offer you better rights or more protection, we will continue to protect your privacy by applying the federal regulations.

EFFECTIVE DATE
This notice takes effect on April 14, 2003.
Version #10403EB