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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. THIS NOTICE IS BEING PROVIDED TO YOU AS REQUIRED BY THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA). PLEASE REVIEW IT CAREFULLY.

Para la versión en español de los anuncios de prácticas de privacidad, por favor haga clic aquí.

This Notice of Privacy Practices describes how Jasper County Hospital, its Agents and Affiliates herein referred to as the "Hospital", may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and relate to your past, present or future physical or mental health or condition and related health care services.

The Hospital is required to abide by the terms of this Notice of Privacy Practices. The Hospital reserves the right to revise and/or update this notice at any time. A new notice would be effective for all protected health information that the Hospital maintains at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. The Hospital's Notice of Privacy Practices may be accessed on it's website at www.jchh.com. You may call the Hospital Compliance Department at (219) 866-5141,extension 2081, to request a revised Notice of Privacy Practices be sent to you in the mail or you may ask for one at the time of your next appointment.

Members of the Hospital Medical Staff, physicians who have been granted privileges to render services to Hospital patients, are participating in an organized health care arrangement with the Hospital. This arrangement provides that while performing services for Hospital patients, they agree to abide by the terms and conditions of this Notice. These physicians include, but are not limited to family practice physicians as well as physicians specializing in orthopedics, oncology, neurology, general surgery, opthalmologists, cardiac care, and dental care. The Hospital may grant privileges to physicians specializing in other areas of medicine when the need arises.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information Based Upon Your Written Consent.

You will be asked by the Hospital to sign a consent form prior to the delivery of services, except in emergency situations. Once you have consented to the use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, the Hospital will use or disclose your protected health information as described in this Section. Your protected health information may be used and disclosed by the Hospital and others outside of the Hospital that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to obtain payment for your health care bills and to support the operations of Jasper County Hospital. Following are examples of the types of uses and disclosures of your protected health care information that the Hospital is permitted to make once you have signed a consent form. These examples are not meant to be comprehensive, but to describe the types of uses and disclosures that may be made by the Hospital once you have provided consent.

Treatment: The Hospital 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 physicians who may be treating you when we have the necessary permission from you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, the Hospital may disclose your protected health information to physicians or health care providers (e.g., a specialist or laboratory) who may become involved in your care by providing assistance with your health care diagnosis or treatment.

Payment: Your protected health information may be used, as needed, to obtain payment for your 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 recommended 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 your health plan to obtain approval for the hospital admission.

Health Care Operations: The Hospital may use or disclose, as needed, your protected health information in order to support the business activities of the Hospital. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical and other students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities.

For example, the Hospital may disclose your protected health information to medical school students who see patients at the Hospital. In addition, a sign-in sheet at the registration desk may be used. You may be asked to sign your name to ensure the registration process is fair for all by allowing patients to register in the order they arrive and for purposes of verifying your attendance for an appointment. The Hospital may also call you by name in the waiting room when a department is ready to see you. The Hospital may use or disclose your protected health information, as necessary, to contact you to advise you of an appointment.

Your protected health information may be shared with a third party or a Hospital "business associate" that may perform various activities (e.g., billing services) for the Hospital. Whenever an arrangement between the Hospital and a business associate involves the use or disclosure of your protected health information, a written contract that contains terms that will protect the privacy of your protected health information will be obtained.

The Hospital may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. It may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about the Hospital and the services it offers. The Hospital may also send you information about products or services that it believes may be beneficial to you. You may contact our Community Relations Department at (219) 866-5141, extension 2130, to request these materials not be sent to you.

The Hospital may use or disclose your demographic information and the dates that you received treatment, as necessary, in order to contact you for fundraising activities supported by the Hospital. If you do not want to be contacted for these purposes, you may contact our Community Relations Department at (219) 866-5141, extension 2130. Individuals accompanying a patient to a care area, or individuals present in the home when health care services are being delivered, will be privy to that patient's medical information. The Hospital cannot control any disclosure of the patient's medical information made by those individuals.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke an authorization, at any time, in writing, except to the extent that the Hospital has taken an action in reliance on the use or disclosure indicated in the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

The Hospital may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of your protected health information, then the Hospital may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Facility Directory: Unless you object, your protected health information will be used and disclosed in the facility directory if you are a registered inpatient, observation patient, same day surgery patient or a resident on the Hospital's long term care floor. Your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation may be used or disclosed. All of this information, except religious affiliation, may be disclosed to people that ask for you by name. Members of the clergy may be told your religious affiliation.

Others Involved in Your Health Care: Unless you object, the Hospital may disclose to a member of your family, a relative, or a close friend, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, the Hospital may disclose such information, as necessary, if it is determined that it is in your best interest based on the Hospital's best professional judgment. The Hospital may use or disclose protected health information to notify, or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, the Hospital may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Emergencies: The Hospital may use or disclose your protected health information in an emergency treatment situation. If this happens, the Hospital shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If the Hospital is required by law to treat you and has attempted to obtain your consent but is unable to do so, your protected health information may be used or disclosed to treat you.

Communication Barriers: The Hospital may use or disclose your protected health information if the Hospital attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the Hospital determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

The Hospital may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required By Law: The Hospital may disclose your protected health information to the extent that law requires the disclosure. The disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such disclosures.

Public Health: The Hospital may disclose your protected health information for public health activities and to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease and reporting injury or disability. Your protected health information may also be disclosed if directed by a public health authority, or to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: The Hospital may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: The Hospital may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: The Hospital may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, your protected health information may be disclosed if it is believed that you have been a victim of abuse, neglect or domestic violence. If either situation is the case, your protected health information will be disclosed to the governmental entity or agency authorized to receive such information. Any disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: The Hospital may disclose your protected health information to a person or company as required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: The Hospital may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court (to the extent such disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: The Hospital may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include

(1) legal processes and otherwise required by law,

(2) limited information requests for identification and location purposes,

(3) pertaining to victims of a crime,

(4) suspicion that death has occurred as a result of criminal conduct,

(5) in the event that a crime occurs on the premises of the Hospital, and

(6) medical emergency (not on the Hospital's premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: The Hospital may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. The Hospital may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. The Hospital may disclose such information in reasonable anticipation of death. Protected health information may be disclosed for cadaveric organ, eye or tissue donation purposes.

Research: The Hospital may disclose your protected health information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.

Criminal Activity: Consistent with applicable federal and state laws, your protected health information may be disclosed if it is believed that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. The Hospital may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, the Hospital may disclose protected health information of individuals who are Armed Forces personnel

(1) for activities deemed necessary by appropriate military command authorities;

(2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or

(3) to foreign military authority if you are a member of that foreign military services. The Hospital may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers' Compensation: Your protected health information may be disclosed by the Hospital as authorized to comply with workers' compensation laws and other similar legally established programs.

Inmates: The Hospital may use or disclose your protected health information if you are an inmate of a correctional facility and the Hospital created or received your protected health information in the course of providing care to you. Required Uses and Disclosures: Under the law, the Hospital must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

2. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as the Hospital maintains the protected health information. A "designated record set" contains medical and billing records and any other records that the Hospital uses for making decisions about you. Any request to inspect or copy your protected health information must be made in writing to the Hospital's Medical Records Department at 1104 E. Grace Street, Rensselaer, Indiana 47978. The Hospital must act on a request to inspect or copy protected health information no later than 30 days after receipt of the request. The Hospital may have one extension of time to act on the request if it provides the requestor with a written statement of the reasons for the delay and the date by which it will complete its actions on the request.

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Medical Records Department at (219) 866-5141, extension 2160, if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask the Hospital 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.

The Hospital is not required to agree to a restriction that you may request. If the Hospital believes it is in your best interest to permit use and disclosure of your protected health information, it will not be restricted. If the Hospital does agree to the requested restriction, it may not use or disclose your protected health information in violation of that restriction unless a disclosure is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with the Hospital during the registration process. You may request a restriction during your registration process by answering the Hospital's restriction questions when asked. You have the right to request and receive confidential communications from the Hospital by alternative means or at an alternative location. The Hospital will accommodate reasonable requests. It may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. No explanation from you as to the basis for the request will be necessary. Please make this request during your registration process.

You may have the right to have the Hospital amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as the Hospital maintains this information. In certain cases, the Hospital may deny your request for an amendment. If your request for an amendment is denied, you have the right to file in writing; a statement of disagreement and the Hospital may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact the Medical Records Department at (219) 866-5141, extension 2160, if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures 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 that may have been 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 that occurred after April 14, 2003. You may request a shorter timeframe. Your request must be made in writing to the Hospital's Medical Records Department at 1104 E. Grace Street, Rensselaer, Indiana 47978. Your request should indicate in what form you want the accounting made (paper, electronic). The first accounting you request will be provided free of charge. Any additional requests for an accounting made for a period of time already provided will be made for a charge. The right to receive this information is subject to certain exceptions, restrictions and limitations. The Hospital must act on a request for an accounting of disclosures no later than 60 days after receipt of the request. The Hospital may have one extension of time (30 days) if it provides the requestor with a written statement of the reasons for the delay and the date by which it will complete its action on the request.

You have the right to obtain a paper copy of this notice from the Hospital upon request.

3. Complaints

If you believe the Hospital has violated your privacy rights, you may file a complaint with the Hospital's Compliance Department or with the Secretary of Health and Human Services. You may contact the Hospital's Compliance Department at 1104 E. Grace Street, Rensselaer, IN 47978 or by calling (219) 866-5141, extension 2081, for further information about the complaint process. The Hospital strictly prohibits any retaliation against you for filing a complaint. If for any reason you are not satisfied with the Hospital's response, you may contact the Secretary of Health and Human Services at 223 N. Michigan Ave., Suite 240, Chicago, Illinois 60601 or by calling (312) 866-2359.

This notice was published and became effective on April 14, 2003.

For questions relating to patient privacy or general compliance issues, please contact our Compliance Hotline at (219) 866-2081.

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