Notice of Privacy Practices

Effective date: 4/01/2005

Notice of Privacy Practices

Effective date : 4/01/2005. 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.

When you visit a healthcare provider a record of your visit is made that contains protected health information. "Protected health information" is information about you that relates to your past, present, or future physical or mental condition and related healthcare services. This Notice of Privacy Practices describes how and when your healthcare provider may use or disclose your protected health information.

We are required by law to maintain the privacy of protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this Notice of Privacy Practices and may change the terms of the notice at any time. The new notice will be effective for all information being maintained at that time. Prior to making any significant changes in our policies, we will change this notice and post the new notice in our waiting area. You may also request and receive a revised Notice of Privacy Practices by accessing our web site at calling the office and requesting a revised copy to be sent to you in the mail, or asking for one at your next appointment.

A.  Uses and Disclosure of Protected Health Information

1. Uses and Disclosures of Protected Health Information Requiring an Authorization:

In situations other than those listed below, we will request your written authorization before using or disclosing any identifiable health information about you. If you choose to sign such authorization to disclose information, you may, in writing, revoke that authorization to stop any future uses and disclosures except to the extent that action has been taken in reliance on the use or disclosure, or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

2. Uses and Disclosures of Protected Health Information That May Be Made with Your Opportunity to Object:

We may use or disclose your protected health information in the following situations after you are informed in advance of the use or disclosure and have the opportunity to agree to, prohibit, or restrict the use or disclosure.

Facility Directories: Unless you object, we will use your name, location where you are receiving care, your general condition, and religious affiliation in our directory. We will disclose this information, except religious affiliation, to anyone who asks for you by name. We will disclose your religious affiliation to clergy members. If you are unable to reject because of an incapacity or emergency situation, we will disclose information in your best interest based on our professional judgment.

Others Involved In Your Healthcare: Unless you object, we will disclose protected health information to a family member, other relative, or a close personal friend, that is directly relevant to the person's involvement in your healthcare or payment related to the healthcare. We may also disclose your information for disaster relief purposes. If you are unable to agree or object we will disclose information as necessary if it is in your best interest based on our professional judgment.

3. Uses and Disclosures of Protected Health Information Not Requiring an Authorization or Opportunity to Object.

Treatment: We will use or disclose your protected health information for treatment including the provision, coordination or management of healthcare, and related services. Treatment extends to consultation between providers or the referral of a patient from one provider to another. For example, a doctor may use your protected health information to determine which treatment option, such as a drug or surgery, best addresses your healthcare needs. Also, information obtained by a therapist will be noted in your record and may be used to determine the course of treatment. Your therapist and other healthcare professional may communicate with each other personally and throughout the case record to coordinate appropriate care.

Payment: Your protected health information will be used for a broad range of activities including obtaining premiums, reimbursement, eligibility and coverage determinations, risk adjustment, billing and claims management coverage and utilization review activities, as well as disclosure to consumer reporting agencies of certain information. For example, in order to receive payment from an insurance company, we must submit paperwork that releases protected health information because it identifies you, your diagnosis, and the treatment provided to you.

Healthcare Operations: We may use or disclose your protected health information to carry out the daily activities of the healthcare provider as they relate to the provision of healthcare. Healthcare operations include but are not limited to due diligence and the transfer of records pursuant to the sale or transfer of assets, or merger of one covered entity with an entity which is or will be a covered entity upon completion of the transaction, quality assessment activities, training medical students, licensing, and marketing and fund raising activities. For example, we may disclose your information to medical students that see patients at the healthcare facility, call you by name in the waiting room, and contact you to remind you of your next appointment. We will share your protected health information with third party "business associates" that perform activities such as billing. We will only disclose protected health information pursuant to a written contract that contains terms that protect the privacy of your protected health information.

Notification: In an emergency situation, we may use or disclose your protected health information to notify or assist in notifying a family member, personal representative, or another person responsible for our care, of your location, and general condition.

Health Related Benefits and Services: We may use your protected health information to provide appointment reminders. For example, we may use dates from your medical record to determine the date and time of your next appointment and send you a reminder notice. Also, we may look at your record and determine that another treatment or new service may be of benefit to you. For example, we may contact a patient to notify them that a research facility that offers life-saving treatments has opened.

Fund Raising Activities: We may use information about you and the treatments you received in order to contact you for fund raising activities. For example, in order to provide improved healthcare for the community we may want to raise additional money and contact you for a donation.

As Required by Law: We may disclose health information for law enforcement purposes as required by law. We will make the disclosure in compliance with the law and you will be notified, as required by law, of any such uses or disclosures.

Public Health Activities: We may disclose your protected health information to a public health authority that is permitted to collect or receive the information. We may be required to report information to help prevent or control disease, injury, or disability. We may also disclose information, if directed by the public health authority, to a foreign government agency that collaborates with the public health authority. This includes reporting child abuse or neglect, FDA regulated product or activity, and exposure to communicable diseases.

Abuse or Neglect: If we believe you have been a victim of abuse or neglect we may disclose your protected health information to an authorized governmental entity or agency. The disclosure will be made pursuant to the requirements of federal and state laws. We may also disclose your information to a public health entity that is authorized to receive reports of child abuse or neglect.

Health Oversight Activities: We may disclose your protected health information to appropriate authorities for activities including but not limited to monitoring, investigating, inspecting, and disciplining or licensing those who work in the healthcare system or for government benefit programs.

Judicial and Administrative Proceedings: We may disclose your protected health information that is expressly authorized by an administrative proceeding, in response to an order of a court or administrative tribunal, and under certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement Purposes: We may disclose your protected health information for law enforcement purposes which include: 1) legal processes; 2) limited information for identification and location purposes; 3) information relating to victims of a crime; 4) decedent information for the purpose of alerting law enforcement when there is a suspicion that death resulted from criminal conduct; 5) crime on the premise; and 6) reporting crimes in emergency situations.

Disclosure About Decedents: We may disclose protected health information about decedents to coroners and medical examiners for the purpose of identifying a deceased individual, determining a cause of death, or carrying out other duties permitted by law. Additionally, we may disclose decedent's information to funeral directors as authorized by law.

Cadaveric Organ, Eye, and Tissue Donations: We may disclose your protected health information to persons involved in the process of obtaining, storing, or transplanting organs, eyes, or tissue of cadavers for donation purposes.

Research: Under certain circumstances we may disclose your protected health information to help conduct research. We may disclose your information only when a review board approves the research and they have a process for ensuring the privacy of your information.

Avoid Threat to Health or Safety: We may disclose information to specified authorities if we believe in good faith that a disclosure of your protected health information is necessary to prevent or minimize a serious threat to you or the public's health or safety.

Military, National Security and Law Enforcement Custody: Under certain conditions, if you are involved with the military, national security, or intelligence activities, we may release your health information to the proper authorities so that they may carry out their duties. Also, if you are in a correctional institution or other law enforcement custodial situation we may disclose your protected health information to a correctional institution or law enforcement official.

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 the law.

Charges Against Provider: In the event you should file suit against us, we may disclose health information necessary to defend such action. Also, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate and determine our compliance with the law.

B. Your Individual Rights

You have several rights with regard to your health information. Specifically you have the right to:

Request a Provider Not to Disclose: You may request, in writing, that we do not use or disclose your information for treatment, payment, or administrative purpose, or to persons involved in your care except when specifically authorized by you, when required by law, or in emergency situations. We will consider your request, however we are not legally required to accept it.

Receive Confidential Communication: You have the right to request that your protected health information be communicated to you in a confidential manner, in certain situations, such as sending mail to an address other than your home.

Inspect and Copy Information: Within the limits of the State statutes and regulations, you have the right to inspect and copy your protected health information. You may not inspect or copy psychotherapy notes, information compiled in anticipation of litigation, or information subject to a law that prohibits access. The decision to deny access may be re viewable in certain cases.

Request to Amend Healthcare Information: If you believe that information in your record in incorrect or if important information is missing, you have the right to submit a request to us to amend your protected health information by correcting the existing information or adding the missing information. We may, under certain circumstances, deny your request.

Receive an Accounting: You have the right to receive an accounting of disclosures of your protected health information. This includes disclosures made other than for treatment, payment, healthcare operation, for a facility directory, to family member or friends involved in your care, requests made by you, pursuant to an authorization, or for notification purposes. The right to receive this information is subject to certain exceptions and limitations.

Receive a Paper Copy of this Notice: If this notice was sent to your electronically, you may obtain a paper copy of the notice upon request.

C. Complaints: If you are concerned that we have violated your privacy rights, or you disagree with a decision we have made about access to your record, you may contact the individual listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The individual listed below can provide you with the appropriate address upon request. Under no circumstances will you be retaliated against for filing a complaint.

D. Contact Information: We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.

If you have any question or complaints, please contact the Privacy Director:

Jeff L. Plemel, RHIT
Shenandoah Medical Center
300 Pershing Avenue
Shenandoah, Iowa 51601
Phone: (712) 246-7280