Notice of Privacy Practices
Effective Date: April 14, 2003
Revision Date: June 1, 2009
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 our Privacy Officer at
WILL FOLLOW THIS NOTICE:
This notice describes our organization's practices and that of:
- Any health care professional authorized to enter
information into your patient record.
- All departments and units of the organization.
- All employees, staff and other organizational
personnel, including volunteer groups associated with
- All these entities, sites and locations will follow the
terms of this notice. In addition, these entities, sites
and locations may share medical information with
each other for the express purpose of treatment,
payment or organizational operation purposes
described in this notice.
OUR PLEDGE ABOUT MEDICAL INFORMATION:
We understand that medical information about you and
your health is personal and we are committed to protecting
that information. We create a record of the care and services
you receive at this organization to enable us to provide you
with quality care and comply with certain legal requirements.
This notice applies to all records of your care generated by
this organization, whether made by hospital personnel, your
personal doctor or other practitioners involved in your care.
This notice will inform you about ways in which we may
use and disclose your medical information. This notice
also describes your rights and certain obligations we have
regarding the use and disclosure of your medical information.
We are required by law to:
- Make sure that medical information that identifies
you is kept private;
- Give you this notice of our legal duties and privacy
practices with respect to medical information about
you; and follow the terms of the notice currently in
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT
The following categories describe different ways we use and
disclose medical information. For each category of uses or
disclosures, we will explain what we mean and try to give
some examples. Not every use or disclosure in a category will
be listed. However, all the ways we are permitted to use and
disclose information will fall within one of the categories.
Other uses and disclosures will be made only with written
authorization and may be revoked at anytime.
FOR TREATMENT: We may use and disclose your
protected health information to provide, coordinate, or
manage your health care and any related services. This
includes the coordination or management of your health care
with a third party that has already obtained your permission
to have access to your protected health information. For
example, we would disclose your protected health information,
as necessary, to a home health agency that provides care to
you. We will also disclose protected health information to
other physicians who may be treating you when we have the
necessary permission from you to disclose your protected
health information. For example, your protected health
information may be provided to a physician to whom you
have been referred to ensure the physician has the necessary
information to diagnose or treat you. In addition, we may
disclose your protected health information, from time-to-time,
to other physician or health care providers (e.g., a specialist
or laboratory) who, at the request of your physicians, have
become involved in your care by providing assistance with your
diagnosis or treatment.
FOR PAYMENT: Your protected health information
may be used, as needed, to obtain payment for health
care services. This may include certain activities that your
health insurance plan may undertake before it approves or
pays for the health care services we recommend for you,
such as making a determination of eligibility or coverage
for insurance benefits, reviewing services provided to you
for medical necessity, and undertaking utilization review
activities. For example, obtaining approval for a hospital
stay may require that your relevant protected health
information be disclosed to the health plan to obtain
approval for admission. You may restrict disclosure of PHI
to your health plans for purposes of payment or health
care operations if you pay the entire cost of the health care
service or item.
FOR HEALTH CARE OPERATIONS: We may
use and disclose medical information about you for
organizational operations. These uses and disclosures are
necessary to run the organization and ensure our patients
receive quality care. For example, we may use medical
information to review our treatment and services and to evaluate the performance of our staff in caring for you.
We may send you a patient satisfaction survey. We may
also disclose information to doctors, nurses, technicians,
health care students, and other organizational personnel
for review and teaching, in which case we may remove
information that identifies you from the records.
APPOINTMENT REMINDERS: We may use and disclose
medical information when contacting you to remind
you of an appointment for treatment or medical care.
REMINDERS: We may use and
disclose medical information when telling you about or
recommending possible treatment options or alternatives
that may be of interest to you.
HEALTH-RELATED BENEFITS: We may use and
disclose medical information when telling you about our
health-related benefits, services, or medical education
classes that may be of interest to you.
FUNDRAISING ACTIVITIES: We may use information
about you to contact you in an effort to raise money
for the hospital and its operations. We may disclose information
about you to a foundation related to the organization
so that the foundation may contact you about raising
money for the organization. In these instances we would
only release contact information, such as your name, address,
phone number and the dates you received treatment
or services at the hospital. If you do not want the hospital
to contact you for fund-raising efforts, you may opt out by
contacting the Foundation Director at (812) 265-0555.
FACILITY DIRECTORY: Unless you object, we may
use and disclose in our facility directory your name, the
location at which you are receiving care, your condition
(in general terms), and your religious affiliation. All this
information, except your religious affiliation, may be
disclosed to people that ask for you by name. Members of
the clergy may be told your religious affiliation.
INVOLVED IN YOUR CARE or PAYMENT FOR YOUR CARE: Health professionals,
using their professional judgment, may disclose to an
individual identified by you (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: We may disclose information to
researchers when their research has been approved by the Executive Committee of the Medical Staff, which reviews
research proposals and establishes protocol(s) to ensure
the privacy of your health information.
AS REQUIRED BY LAW: We will disclose medical
information about you when required to do so by federal,
state or local law.
Organ and Tissue Donation: If you are an
organ donor, we may release medical information to
organizations that handle organ procurement or organ,
eye, or tissue transplantation or to an organ donation
bank. We will do this as necessary to facilitate organ or
tissue donation and transplantation.
Military: If you are a member of the armed forces, we
may release medical information about you as required by
military command authorities. We may also release medical
information about foreign military personnel to the
appropriate foreign military authority.
Workers' Compensation: We may release medical information
about you for workers’ compensation or similar
programs. These programs provide benefits for work-related
injuries or illness.
Public Health Risks (Health and Safety to you and/or others): We may use and disclose medical information
about you to appropriate agencies when necessary
to prevent a serious threat to your health and safety or
the health and safety of the public or others. Reasons for
disclosure generally include the following: To prevent or
control disease, injury, or disability; to report births and
deaths; to report child abuse or neglect; to report reactions
to medications or problems with products; to notify
people of recalls of products they may be using; to notify
a person who may have been exposed to a disease or may
be at risk for contracting or spreading a disease or condition;
to notify the appropriate government authority if we
believe a patient has been the victim of abuse, neglect or
domestic violence. We will only make these disclosures
when required or authorized by law.
Health Oversight Activities: We may disclose medical
information to health oversight agencies for activities
authorized by law. These oversight activities include for
example: audits, investigations, inspections and licensure.
These activities are necessary for the government to
monitor the health care system, government programs and
compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit
or dispute, we may disclose medical information about
you in response to a court or administrative order. We
may also disclose medical information about you in
response to a subpoena, discovery request, or other lawful
process by other parties involved in the dispute.
Law Enforcement: We may release medical information
if asked to do so by law enforcement officials:
- In response to a court order, subpoena, warrant,
summons or similar process;
- To identify or locate a suspect, fugitive, material
witness, or missing person;
- About the victim of a crime if, under certain limited
circumstances, we are unable to obtain the person’s
agreement to release information;
- About a death we believe may be the result of
- About criminal conduct at the facility; and
- In emergency circumstances to report a crime.
Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical
examiner. This may be necessary, for example, to identify a
deceased person or determine a cause of death. We may also
release medical information about patients of the hospital to
funeral directors, as necessary, to carry out their duties.
National Security and Intelligence Activities: We
may release medical information about you to authorized
federal officials for intelligence, counterintelligence, and
other national security activities authorized by law.
Protective Services for the President and Others: We may disclose medical information about you to
authorized federal officials so they may provide protection
to the President, other authorized persons or foreign
heads of state.
Inmates: If you are an inmate of a correctional facility or
under the custody of law enforcement officials, we may
release medical information about you to the correctional
institution or law enforcement officials.
YOUR RIGHTS REGARDING
MEDICAL INFORMATION ABOUT YOU:
You have the following rights regarding medical information
we maintain about you:
Right to Inspect and Copy: You have the right to
inspect and copy medical information that may be used
to make decisions about your care. Usually, this includes medical and billing records, but does not include
To inspect and copy medical information that may be
used to make decisions about you, you must submit your
request in writing to Health Information Management
Services. If you request a copy of the information, we may
charge a fee for the cost of copying, mailing or other supplies
associated with your request.
We may deny your request to inspect and copy in certain
very limited circumstances. If your request is denied, you
may request that the denial be reviewed. Another licensed
health care professional chosen by the organization
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
Right to Amend: If you feel that medical information
about you is incorrect or incomplete, you may ask us to
amend the information. You have the right to request
an amendment for as long as the information is kept
by or for the organization. To request an amendment,
your request must be made in writing and submitted to
Privacy Officer at (812) 265-0121. In addition, you must
provide a reason that supports your request.
- We may deny your request for amendment if it
is not in writing or does not include a reason to
support the request. In addition, we may deny your
request if you ask us to amend information that:
- Was not created by us, unless the person or entity
that created the information is no longer available
to make the amendment;
- Is not part of the medical information kept by or
for the hospital;
- Is not part of the information which you would be
permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures: You
have the right to receive an accounting of certain
disclosures we have made, if any, of your protected
health information. This right applies to disclosures
for purposes other than treatment, payment or
healthcare operations as described in this Notice of
Privacy Practices. It excludes disclosures we may have
made to you, for a facility directory, to family members
or friends involved in your care, or for notification
purposes. You have the right to receive specific
information regarding these disclosures if they occurred
after April 14, 2003.
Right to Request Restrictions: You may ask us not to
use or disclose any part of your protected health information
for the purposes of treatment, payment or healthcare
operations. You may also request that any part of your
protected health information not be disclosed to family
members or friends who may be involved in your care
or for notification purposes as described in this Notice
of Privacy Practices. Your request must state the specific
restriction requested and to whom you want the restriction
to apply. However, we are not required to agree to a
Alternative Communications: You have the right to
request to receive confidential communications from us
by alternative means or at an alternate location. We will
accommodate reasonable requests. We may also condition
this accommodation by asking you for information
as to how payment will be handled after specification of
an alternative address or other method of contact. Please
make this request in writing to our Privacy Officer.
Right to a Paper Copy of this
Notice: You have the
right to a paper copy of this privacy notice, upon request,
even if you have agreed to accept this notice electronically.
TO THIS NOTICE: We reserve the right
to change this notice at any time. We reserve the right to
make the revised or changed notice effective for medical
information already on record about you as well as
any information we receive in the future. We will post a
copy of the current notice in the facility. The notice will
contain on the first page the effective date. In addition,
each time you register at or are admitted to the facility
for treatment or health care services as an inpatient or
outpatient, we will offer you a copy of the current notice
COMPLAINTS: If you believe your privacy rights have
been violated, you may submit your complaint via:
- The Privacy Officer at (812) 265-0121
- The Compliance Integrity Line at (812) 265-0222
- The Mail:
King’s Daughters’ Hospital
P.O. Box 447
Attn: Privacy Officer
Madison, IN 47250
- Secretary of the Department of Health & Human
Services via http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
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