Joint Notice of Privacy Practices

**PLEASE REVIEW IT CAREFULLY**

This Joint Notice applies to Montgomery County Memorial Hospital (MCMH) departments, employees, healthcare professionals, and independent providers who use or disclose your protected health information to carry out treatment, initiate payment, conduct healthcare operations, and for other purposes that are permitted or required by law. Our medical campus allows patients to receive care from both hospital staff and independent providers who share your health information that is generated from your inpatient and outpatient visits. Independent providers include the local Red Oak area physicians and various healthcare professionals that hold outpatient clinics in this facility who participate in an Organized Health Care Arrangement.

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION

We understand that information about you and your health is personal and we are committed to protecting your private information. Each time you visit a record is generated to record the care and services that you receive and these health records are contained in a file that is the physical property of MCMH. We pledge that any health information that is necessary to be shared will be kept strictly confidential and shared only with those who need to know it. Uses and disclosures of your health information for other than permitted or required purposes will only be made with your written authorization and allowable revocation.

HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

MCMH is permitted to use or disclose your health information for the following purposes, without your written authorization:

Treatment: We may use your health information to provide you with medical treatment or services. We may disclose information about you to doctors, nurses, technicians, medical students, or other authorized personnel who are involved in taking care of you. Different departments may share information about you in order to coordinate the different services you need, such as lab work, x-rays, or prescriptions. We may also disclose information about you to people outside the hospital who may be involved in your medical care, such as family members, clergy, or others that we use to provide services that are part of your care. Example: If your doctor refers you to a specialized physician or to a home health agency, we will disclose your private health information, as necessary, so they will have critical information to continue your treatment or care.

Payment: We may use and disclose your health information to others so that the treatment and services that you receive may be billed and payment may be collected from you or your insurance company. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment. We may also inform your insurance company about a treatment or service you are going to receive to obtain prior approval, or to determine whether your insurance will cover the treatment or service. Example: We will give your insurance company billing information about the surgery you received at the hospital so your insurance company will pay us for the surgery charges.

Health Care Operations: We may use and disclose your health information for operational or administrative purposes that are necessary to support the business activities of the hospital and to make sure that all of our patients receive the highest quality of care, such as quality assessment or improvement activities. Example: Your health information may be disclosed to members of the medical staff or quality improvement staff to assess the quality of our treatment and services; to evaluate the performance of our staff in caring for you; or to determine how to improve our facilities, services, quality, and effectiveness of the healthcare we provide.

We may also disclose your health information to third party business associates that perform various activities for us, under written contracts that contain terms and conditions to protect the privacy of your health information.

Appointment Reminders: We may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital.

Treatment Alternatives: We may use and disclose your health information to recommend possible treatment options or alternatives to you; or to tell you about other health-related benefits and services that may be of interest.

MCMH is permitted to use or disclose your health information for the following purposes, unless you tell us that you object:

Directory of Patients: We may include your name, location, general condition, and religious affiliation in the directory while you are a patient at the hospital. This information may be provided to members of your family, friends, members of the clergy, and except for religious affiliation, to other people who ask for you by name.

Involvement in Your Care: We may release your health information to a family member, other relative, close personal friend, or any other person you identify who is involved in your care or helps pay for your care. We may use or disclose your information to notify a family member or another person responsible for your care about your location, general condition, or death. In an emergency situation or circumstance where you are unable to agree or object, we will use our professional judgment to determine your best interest and disclose only the information that is directly relevant to the person’s involvement in your healthcare. We may also disclose your information to an authorized agency assisting in disaster relief in an effort to notify your family.

Fundraising Activities: We may use your personal information to contact you in an effort to raise money for the hospital and its operations. We may disclose your information to a foundation related to the hospital so that the foundation may contact you to raise money for the hospital. We will only release contact information (name, address, phone) and the dates you received treatment.

MCMH is required to disclose your health information for the following purposes:

Required by Law: We may disclose your health information when required to do so by federal, state or local law – to report crime or suspected abuse, neglect or domestic violence; any judicial proceeding in response to a court order or subpoena; or to assist law enforcement officials with their official duties.

Public Health: We may disclose your health information when reporting public health risks to prevent or control disease, injury, or disability; to report births, deaths, child abuse or neglect; to report reactions to medications, problems or recalls with products; or health oversight activities authorized by law such as audits, investigations, inspections or licensures to determine that our facility is in compliance with specific laws and regulations.

Decedents: We may disclose health information about a deceased patient to funeral directors, coroners, or medical examiners to enable them to carry out their lawful duties; and to organ procurement organizations for the purpose of facilitating organ, eye or tissue donations and transplantations.

Research: We may use or disclose your health information for research approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of it.

Health and Safety: We may disclose your health information to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions: We may disclose health information of armed forces personnel or veterans as required by military command or authorities; to authorized federal officials for intelligence, counterintelligence, or other national security activities; and to correctional institutions or law enforcement officials if you are an inmate.

Workers’ Compensation: We may disclose your health information in order to comply with laws and regulations related to Workers’ Compensation programs.

Other Uses: Other uses and disclosures of your health information not covered by this Joint Notice or the laws that apply to us will be made only with your written authorization, until you revoke that authorization.

Your RIGHTS

Your health record is the physical property of MCMH, however you have the right to:

• receive a paper copy of the Joint Notice of Privacy Practices

• inspect and receive a copy of your health record, except psychotherapy notes;

• authorize release of your medical record for use and disclosure to a specified individual or entity;

• revoke an authorization except to the extent MCMH has already taken action in reliance on the authorization;

• request in writing that your health record be amended if you think it is incorrect or incomplete;

• request a restriction on certain uses and disclosures of your health record – however MCMH is not required to agree to your request for a restriction;

• request communication of your record by alternative means or at alternative locations;

• receive an accounting of disclosures made of your health information after April 14, 2003.

MCMH RESPONSIBILITIES

We are required by the federal law, “Health Insurance Portability and Accountability Act of 1996” to:

• protect the privacy of your personal health information;

• provide you with a copy of our Joint Notice of our legal duties and privacy practices;

• abide by the terms of the Joint Notice that is currently in effect;

• notify you if we are unable to agree to a requested restriction on how your information is used or disclosed; and

• accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations.

ORGANIZED HEALTH CARE ARRANGEMENT

For purposes of this Joint Notice, “MCMH” refers to the hospital and to independent providers which includes Red Oak area physicians and various healthcare professionals who hold outpatient clinics at this facility and have entered into an Organized Health Care Arrangement (OHCA). Under this OHCA the hospital and eligible independent providers will use this Joint Notice for all inpatient and outpatient visits; will obtain a single signed acknowledgment of receipt for this Joint Notice; will share protected health information from inpatient and outpatient hospital visits; and will follow the privacy practices described herein. This Joint Notice and the OHCA do not cover the privacy practices of the independent providers at their private offices or at other locations.

COMPLAINTS

You may make written complaints to MCMH or to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. Your complaint may be filed in writing to the department listed below. We will not retaliate against you for filing a complaint.

Contact Information

Quality Management Department

Montgomery County Memorial Hospital

2301 Eastern Avenue

PO Box 498

Red Oak, IA 51566

Phone: 712-623-7144

CHANGES TO THIS JOINT NOTICE

If our information practices change, we may change our Joint Notice of Privacy Practices and the changes will be effective for all protected health information that we maintain. A revised Joint Notice will be made available to you upon request by mail or at the time of your next appointment following the change. We will post a copy of our new Joint Notice in the Admissions area and on our website at www.mcmh.org.

JOINT NOTICE OF PRIVACY PRACTICES