“Where Your Needs—Become Our Cares”

Privacy Practices

PUTNAM COUNTY MEMORIAL HOSPITAL

& RURAL HEALTH CLINIC

P.O. Box 389, 1926 Oak Street

Unionville, Missouri 63565-0389

Phone (660) 947-2411 or 2412

Fax (660) 947-3825

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.

Understanding Your Health Record / Information

Each time you visit Putnam County Memorial Hospital and Rural Health Clinic, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as:

· Basis for monitoring and planning your care and treatment;

· Means of communication among the many health 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 services billed were actually provided;

· Tool in educating health professionals;

· Source of data for medical research in some instances;

· Source of information for public health officials who oversee the delivery of health care in the United States;

· Source of data for facility planning and marketing; and tool with which we can assess and continually work to improve the care we render and the outcome we achieve.

· Understanding what is in your record and how your health information is used helps you to:

· Ensure its accuracy;

· Better understand who, what, when, where, and why others may access your health information; and make more informed decisions when authorizing disclosure to others.

Our Responsibilities

Federal Law imposes certain obligations and duties upon us as a covered health care provider with respect to your Protected Information. Specifically, we are required to:

· Provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you;

· Maintain the privacy and confidentiality of your Protected Information in accordance with state and federal law;

· Notify you if we are unable to agree to a restriction you have requested;

· Allow you to inspect and/or obtain a copy of your Protected Information during our regular business hours;

· Act on your request to amend Protected Information within sixty (60) days and notify you of any delay which would require us to extend the deadline by the permitted thirty (30) day extension;

· Accommodate reasonable requests to communicate Protected Information by alternative means or methods; and abide by the terms of this notice.

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

We reserve the right to change our practices with respect to Protected Health Information and to amend this notice. Should our information practices change, a revised notice will be posted in the hospital and available to you upon request from the privacy officer and/or admissions personnel.

How We Will Use Or Disclose Your Health Information

Treatment: We may use and/or disclose your Protected Health Information for treatment purposes.

Example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you have been discharged from our facility.

Payment: Your Protected Health Information may be used and/or disclosed for the purpose of payment.

Example: A bill may be sent to you or a third-party payer, including Medicare and/or Medicaid. The information on or accompanying that bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Health Care Operation: Your Protected Health Information may be use and/or disclosed for the purpose of regular health care operations.

Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team 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 health care and services we provide. In addition, we may disclose your Protected Health Information to another individual or entity covered by the privacy regulations that has a relationship with you for their fraud and abuse detection or compliance purposes, quality assessment and improvement activities, or review, evaluation or training of health care professionals or students.

Health Oversight Activities: Your Protected Information may be used or disclosed to a health oversight agency for activities authorized by law. Examples of health oversight activities include audits, investigations, inspections or judicial/administrative proceedings, which you are not the subject of. In most cases, the oversight activity will be for the purpose of overseeing the care rendered by our facilities or our facilities’ compliance with certain laws and regulations.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include our accountants, consultants, and attorneys. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. However, to protect your health information, we require the business associate to

appropriately safeguard your information. This is done through a Business Associate Agreement.

Directory: Putnam County Memorial Hospital maintains a patient directory. Unless you notify us that you object, we may use and/or disclose your name, location in the hospital, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. We may also use your name on a name-plate next to or on your door in order to identify your room, unless you notify us that you object.

Notification: We may use and/or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided us, e.g., on an answering machine. The information left as a message will be limited to your name,

location, and general condition.

Communication with Family: Health professionals, using their best professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Research: In some instances, your Protected Information may be used and/or disclosed for research purposes. All research projects, in which Protected Information may be used and/or disclosed, are subject to a special approval process, which will evaluate the precautions used to protect your health information. In many cases, information, which identifies you, will be removed.

Coroner, Medical Examiners, Funeral Directors: We may disclose health information to funeral directors, coroners, and medical examiners to carry out their duties consistent with applicable law.

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 organ, tissue, and/or bone for the purpose of organ, tissue, and/or bone donation and transplant.

Marketing: We may contact you for follow-up and/or to provide appointment reminders. We may also contact you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund Raising : We may contact you as part of a fund-raising effort.

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

Law Enforcement: We may disclose your Protected Health Information for law enforcement purposes required by law, such as:

· Pursuant to a court order, warrant, subpoena/summons or administrative request;

· Identifying or locating a suspect, fugitive, material witness or missing person;

· Regarding a crime victim, but only if the victim consents or the victim is unable to consent due to incapacity, and the information is needed to determine if a crime has occurred, non-disclosure would significantly hinder the investigation, and disclosure is in the victim’s best interest;

· Regarding a decedent, to alert law enforcement that the individual’s death was caused by suspected criminal conduct; or

· By emergency care personnel if the information is necessary to alert law enforcement of a crime, the location of a crime, or characteristics of the perpetrator.

Correctional Institution: Should you be in the custody 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.

Workers Compensation: We may disclose health information to the extent authorized by, and to the extent necessary to comply with law 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.

Specialized Government Functions: Your protected information may be used and/or disclosed for a variety of government functions subject to some limitations. These government functions include:

· Military and veterans activities;

· National security and intelligence activities;

· Protective service of the President and others;

· Medical suitability determinations for Department or State Officials;

· Correctional institutions and law enforcement custodial situations; or

· Provisions of public benefits.

More Stringent Laws: Some of your protected information may be subject to other laws and regulations and afforded greater protection than what is outlined in this notice. For example, HIV/AIDS, substance abuse, and mental health information are given more protection. In the event your protected information is afforded greater protection under federal or state law, we will comply with the applicable law.

Other: Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force 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 Putnam County Memorial Hospital and Rural Health Clinic, the information in your health record belongs to you, and you have the following rights:

· You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.

· Your have the right to request a restriction on certain uses and disclosures of your protected information. You must make such request in writing on a form provided by our facility. Please note, that we will attempt to accommodate all reasonable requests, and you will receive a response to your request from the Privacy Officer and/or designee.

· You have the right to request communications of your protected information be done by alternative means or at alternative locations. Such requests must be made in writing on a form provided by our facility. Please note that we will try to accommodate all reasonable requests, and you will receive a response to your request from the Privacy Officer and/or designee.

· You have the right to request to amend your health record. If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request amendment to your record, including a reason for request in writing on a form provided by our facility. You will receive a response to your request from the Privacy Officer and/or designee.

· You have the right to revoke your authorization to use and/or disclose health information except to the extent that action has already been taken. This request must be made in writing on a form provided by our facility. You will receive a response to your request from the Privacy Officer and/or designee.

· You have the right to request an accounting of disclosures of your health information made by our facility (not to exceed 6 years). Such request must be made in writing on a form provided by our facility. Please note that an accounting will not apply to any of the following types of disclosures:

· Disclosures made for the purpose of treatment, payment, or health care operations; o Disclosures made to you or your legal representative or any other individual involved with your care;

· Disclosures to correctional institutions or law enforcement officials;

· Disclosures for national security purposes; or

· Disclosures prior to the Privacy Rule Compliance Date of April 14, 2003.

· You will not be charged for your first accounting request in any 12-month period. However, for any additional request you make thereafter, you will be charged a reasonable, cost-based fee.

· You have the right to inspect and obtain a copy of your health record. This will be provided in the time frame established by law. If you request copies, we will charge you our standard fee for copying Health Information. Such request must be made in writing on a form provided by our facility. You will receive a response to your request from the Privacy Officer and/or designee.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Putnam County Memorial Hospital & Rural Health Clinic Privacy Officer at 660-947-2411.

If you believe that your privacy rights have been violated, you may file a complaint with us. This complaint must be filed in writing on a form provided by our facility. The complaint form may be obtained from the Privacy Officer and/or designee, and when completed, should be returned to the Privacy Officer and/or designee. You may also file a complaint with the secretary of the federal Department of Health and Human Services.

There will be no retaliation for filing a complaint.

Effective Date: This notice is effective as of Tuesday, April 1, 2003.

Putnam County Memorial Hospital

1926 oak Street

Unionville, Missouri 63565

Phone: 660-947-2411

Fax: 660-947-3825

kbradshaw@pcmhosp.com