Notice of Privacy Practices

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PERRY COUNTY MEMORIAL HOSPITAL
JOINT 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.

OUR DUTIES
Perry County Memorial Hospital (PCMH) is dedicated to safeguarding the confidentiality of any and all medical and other personal information provided to it.
PCMH is required by law to:
-Maintain the privacy of protected health information;
-Provide notice of our legal duties and privacy practices; and
-Abide by the terms of our Notice of Privacy Practices currently in effect.

WHO WILL FOLLOW THIS NOTICE
The practices described in this Notice apply to PCMH and the following persons and groups of persons:
-PCMH employees, contract employees, staff and trainees, students, residents in training and volunteers
-PCMH Emergency Medical Services (EMS)
-PCMH Board of Trustees
-PCMH Home Care Services
-PCMH medical staff, including physicians and allied health professionals with privileges to practice at PCMH and the staff members of such physicians who work at PCMH
-All departments and units of PCMH, including provider clinics owned by PCMH
All of these entities, sites and locations follow the terms of this Notice. In addition, these entities, sites and locations may share health information with each other for treatment, payment or operations purposes described in this Notice.

PROTECTED HEALTH INFORMATION
Protected Health Information (PHI) means individually identifiable health information, as defined by the Health Insurance Portability and Accountability Act (HIPAA), that is created or received by PCMH and that relates to past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and that identifies the individual or for which there is a reasonable basis to believe the information can be used to identify the individual. PHI includes genetic information, including genetic services and tests. PHI includes information of persons living or deceased. PHI excludes individually identifiable health information of persons who have been deceased for more than 50 years.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATON
How PCMH May Use Your Protected Health Information

Treatment: PCMH will use or disclose your PHI as necessary for PCMH and other health care providers to provide medical care, or related services, to you. We may disclose your health information to doctors, nurses, aids, technicians or other employees who are involved in taking care of you. Additionally, we may use or disclose your health information to manage or coordinate your treatment, health care or other related services. For example: PCMH will use your medical history to assess your health and perform requested diagnostic services. PCMH may also disclose your PHI to other health care providers (doctors, nurses, therapists, etc.) not affiliated with PCMH who are providing medical care to you.

Payment: PCMH will use and disclose your PHI to obtain payment for services provided to you by PCMH and as necessary to assist other health care providers, health plans and health care clearinghouses in obtaining payment for health care services provided to you. For example: After you have received services, PCMH will send a bill identifying you, your diagnosis and the services you received to your insurer, to you or to a collection service.

Health Care Operations: PCMH may use and disclose your PHI for PCMHs health care operations or the limited types of health care operations of other health care providers, health care plans and health care clearinghouses that have a relationship with you. For example: PCMH may arrange for accrediting organizations, auditors or other consultants to review PCMHs practices and operations to conduct performance improvement and quality assurance activities. In addition, we may disclose your medical information to any of the entities included in PCMH's organized health care arrangement for purposes of health care operations of the organized health care arrangement.

Incidental Uses and Disclosures: We may occasionally inadvertently use or disclose your medical information when such use or disclosure is incident to another use or disclosure that is permitted or required by law. For example, while we have safeguards in place to protect against others overhearing our conversations that take place between doctors, nurses or other PCMH personnel, there may be times that such conversations are in fact overheard. Please be assured, however, that we have appropriate safeguards in place to avoid such situations, and others, as much as possible.

Disclosures to You: Upon a request by you, we may use or disclose your medical information in accordance with your request.

Limited Data Sets: We may use or disclose certain parts of your medical information, called a "limited data set," for purposes of research, public health reasons or for our health care operations. We would disclose a limited data set only to third parties that have provided us with satisfactory assurances that they will use or disclose your medical information only for limited purposes.

Disclosures to the Secretary of Health and Human Services: We might be required by law to disclose your medical information to the Secretary of the Department of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether we are complying with privacy laws.

De-Identified Information: We may use your medical information, or disclose it to a third party whom we have hired, to create information that does not identify you in any way. Once we have de-identified your information, it can be used or disclosed in any way according to law.

Disclosures by Members of Our Workforce: Members of our workforce, including employees, volunteers, trainees or independent contractors, may disclose your medical information to a health oversight agency, public health authority, health care accreditation organization or attorney hired by the workforce member, to report the workforce member's belief that we have engaged in unlawful conduct or that our care or services could endanger a patient, workers or the public. In addition, if a workforce member is a crime victim, the member may disclose your medical information to a law enforcement official.

Appointment Reminders: PCMH may use and disclose PHI to contact you as a reminder that you have an appointment or that it is time to schedule an appointment. If you do not wish us to contact you for this purpose, you must notify in writing the person named on the last page of this Notice.

Treatment Alternatives, Benefits and Services: PCMH may disclose your PHI to tell you about possible treatment options or alternatives, health-related benefits or other services that may be of interest to you or to recommend possible treatment options or alternatives that may be of interest to you. If you do not wish us to contact you for this purpose, you must notify in writing the person named on the last page of this Notice.

Individuals Involved in Your Care or Payment for Your Care: Unless you object, PCMH may discuss your health care with members of your family, close friends or other individuals you identify who may be involved in your care or the payment for your care. If you have a mental health diagnosis, no information about you will be shared with your family, friends or others identified by you without your explicit, written permission.

Research: PCMH may use or disclose certain PHI about your condition and treatment for research purposes where an Institutional Review Board or similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. PCMH may also use and disclose your PHI to prepare or analyze a research protocol and for other research purposes.

Fundraising: PCMH may use your PHI to contact you for the purposes of raising funds to support PCMH and its mission. You have the right to opt of receiving fundraising communications and may do so notifying in writing the person named on the last page of this Notice.

PCMH Business Associates: PCMH sometimes works with outside individuals and businesses that help PCMH successfully operate its business. PCMH may disclose your PHI to these businesses so that they can perform the tasks that PCMH hires them to perform. PCMH requires its business associates to certify that they will respect and protect the confidentiality of your health information.

Facility Directory: We may include certain limited information about you in our directory. This information may include your name, location in the Hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do not ask for you by name. If you do not wish to be included in the facility directory, you will be given an opportunity to object at the time of admission.

Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to a family member, other relative, or any other person identified by you who is involved in your health care. We may also give information to someone who is involved with or helps pay for your care. We may also tell your family, friends, personal representative or other person responsible for your health care your condition and that you are at the Hospital.

Third Parties: We may disclose your health information to certain third parties with whom we contract to perform services on our behalf. If we disclose your information to these entities, we will have an agreement by them to safeguard your information.

Communications Regarding PCMHs Programs or Products: We may use and disclose your health information to make a communication to you to describe a health-related product or service of PCMH. In addition, we may use or disclose your health information to tell you about products or services related to your treatment, case management or care coordination, or alternative treatments, therapies, providers or settings of care for you. We may occasionally tell you about another company's products or services, but will use or disclose your health information for such communications only if they occur in person with you. We may also use and disclose your health information to give you a promotional gift from us that is of minimal value.

Disclosures of Records Containing Drug or Alcohol Abuse Information: Because of federal law, we will not release your medical information if it contains information about drug or alcohol abuse without your written permission except in very limited situations.
How PCMH is Required by Law to Disclose Your Protected Health Information

Required by Law: PCMH may disclose your PHI when required to do so by federal, state or local law.

Public Health Activities: PCMH may disclose your PHI in connection with certain public health reporting activities. For instance, PCMH may disclose your PHI to a public health authority authorized to collect or receive PHI for the purpose of preventing or controlling disease, injury or disability; reporting births and deaths; reporting defective medical devices or problems with medications; notifying people of recalls of products they may be using; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority. Public health authorities include, but are not limited to, the Perry County Health Department (PCHD), the Indiana State Department of Health (ISDH), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA).

Abuse and Neglect: PCMH is also permitted to disclose PHI to a public health authority or other government agency authorized by law to receive reports of child abuse or neglect, domestic violence or abuse or elder abuse or neglect. We will only make this disclosure if you agree or when required or authorized by law.

FDA Reports: PCMH may disclose PHI to the FDA for purposes of reporting adverse events, product defects/problems or biological product deviations, tracking products, enabling product recalls, repairs or replacements or conducting post-marketing surveillance.

Health Care Oversight Activities: PCMH may disclose your PHI in connection with the health care oversight activities of licensing and other agencies. Health care oversight activities include, but are not limited to: audit; investigation; inspection; licensure or disciplinary actions; civil, criminal or administrative proceedings or actions; or any other activity necessary for the oversight of 1) the health care system. 2) governmental benefit programs for which health information is relevant in determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which health information is necessary for determining compliance with program standards, or 4) entities subject to civil rights laws for which health information is necessary for determining compliance.

Threat to Health and Safety: PCMH may disclose PHI when necessary to prevent a serious threat to your health or safety or to the health and safety of others. Any disclosure, however, would only be to someone able to help prevent or lessen the threat or to law enforcement authorities in particular circumstances.

Workers' Compensation: We may disclose your health information as authorized by and to the extent necessary to comply with workers' compensation laws or laws relating to similar programs.

National Security and Intelligence: PCMH may disclose PHI for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.

Judicial Purposes: We may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell you about the request, in which you were given an opportunity to object to the request, or to obtain an order protecting the information requested.

Law Enforcement: We may release health information if asked to do so by a law enforcement official, if such disclosure is:
-Required by law;
-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;
-About a death we believe may be the result of criminal conduct;
-About criminal conduct at PCMH; or
-In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Special Circumstances Requiring PCMH to Disclose Your Protected Health Information

Coroners, Medical Examiners and Funeral Directors: PCMH may disclose PHI to a coroner, medical examiner and/or funeral director to assist in identifying a deceased person, determining the cause of death or to otherwise enable them to perform their duties.

Organ and Tissue Procurement: PCMH may release PHI to organ procurement organization, transplant centers and eye or tissue banks.

Military: If you are a member of the Armed Forces, PCMH may release your PHI as required by military command authorities. PCMH may also release the PHI of foreign military personnel to the appropriate foreign military authority.

Inmates: If you are an inmate at a correctional facility, PCMH may release PHI about you to the correctional institution where you are incarcerated or to law enforcement officials.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
PCMH is required to obtain written authorization from you for any uses and disclosures of your PHI other than those described above. For example, PCMH will not sell your PHI, disclose your PHI for marketing purposes or disclose psychotherapy notes about you without your express written authorization. If you provide PCMH with such an authorization, you may revoke that authorizationXin writingXat any time. If you revoke your authorization, PCMH will no longer use or disclose PHI about you for the reasons covered by your written authorization. PCMH cannot be held responsible for valid disclosures of PHI made under an effective authorization prior to your revocation of that authorization.

PCMH is required by law to notify you if your PHI maintained by PCMH is affected by a security breach.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding health information we maintain about you:

Right to Request Restrictions: You have the right to ask, in writing, for restrictions on the ways PCMH uses and discloses your PHI beyond those imposed by law. PCMH will consider your request, but in some cases, is not required to agree to it. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to PCMHs Health Information Management (Medical Records) Department. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

Right to Request Restrictions on Disclosures to Health Plans: You have the right to restrict disclosures of PHI to a health plan with respect to health care services for which you have paid out of pocket in full. PCMH must agree to your request if the disclosure to the health plan is for the purpose of carrying out payment or health care operations and is not required by law and the PHI pertains solely to a health care item or service for which you or a person on your behalf (other than the health care plan) have paid PCMH for in full. Requests of this nature should be made before the health care service is provided.
Right to Request Alternate Delivery of Information: You have the right to request, in writing, that you receive communications containing your PHI from PCMH by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. PCMH is not required to agree to such requests that it considers are unreasonable.

To request confidential communications, you must make your request in writing to PCMHs Health Information Management (Medical Records) Department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Inspect and Copy: Except under certain circumstances, you have the right to inspect and copy PHI maintained about you by PCMH. If you ask for copies of this information, PCMH may charge you a fee for copying and mailing the information. Under some circumstances, if PCMH denies your request to inspect your PHI, you may request in writing that the denial be reviewed. To inspect and copy health information that may be used to make decisions about you, you can submit your request in writing to the PCMHs Health Information Management (Medical Records) Department. You may request that PCMH transmit a copy of your PHI to a person designated by you.

Right to Amend Information: If you believe that the PHI about you by PCMH is incorrect or incomplete, you have the right to request, in writing, that PCMH correct or amend the information. Under certain circumstances, PCMH may deny your request.

To request an amendment, your request must be made in writing and submitted to PCMHs Health Information Management (Medical Records) Department. In addition, you must provide a reason that supports your request.
We may deny your request for an 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 health information kept by or for us;
-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 a right to ask, in writing, for a list of certain instances when PCMH has disclosed your PHI for reasons other than your treatment (by PCMH or other health care providers), payment for services furnished to you (by PCMH or other health care provides), PCMHs health care operations, certain health care operations of other entities or disclosures you authorize us to make. The period of time covered by your request may not exceed six years and your request may not include uses or disclosures made before April 14, 2003. The first list of disclosures requested within any 12-month period will be free. If you ask for this information more than once every twelve months, PCMH may charge you a fee. Requests for an Accounting of Disclosures should be submitted, in writing, to PCMHs Health Information Management (Medical Records) Department.

Right to Receive a Paper Copy of This Notice upon Request: If you received an electronic version of this Notice, you have the right to obtain a paper copy of this Notice.
You may obtain a copy of this Notice at our web site at www.pchospital.org.
To obtain a paper copy of this Notice, contact the person listed on the last page of this Notice.

COMPLAINTS
If you have complaints about PCMHs privacy practices, please contact:
Privacy Officer
Perry County Memorial Hospital
1 Hospital Road
Tell City, Indiana 47586
Telephone: (812) 547-7011

All complaints must be submitted in writing.
You may also register complaints about PCMHs privacy practices by contacting the Secretary of the United States Department of Health and Human Services, Washington, D.C.
PCMH will not interfere with your right to file a complaint concerning its privacy practices and will not retaliate against you for filing a complaint.

CHANGES TO THIS NOTICE
PCMH reserves the right to make changes to this Notice at any time. PCMH reserves the right to make the revised Notice effective for health information PCMH already has about you as well as for any health information PCMH receives about you in the future. In the event this Notice is revised, a copy of the revised Notice will be made available to you the first time you seek or receive services from PCMH after the effective date of the revised Notice. This Notice will contain on the bottom of the last page, the effective date. A copy of the revised Notice will also be posted in a prominent location within the Hospital, in other facilities operated by PCMH and on PCMH's website. You also have the right to request a copy of the revised Notice.

REQUESTS FOR ADDITIONAL INFORMATION
If you have questions about PCMHs privacy practices or this Notice, please call or write:
Privacy Officer
Perry County Memorial Hospital
1 Hospital Road
Tell City, Indiana 47586
Telephone: (812) 547-7011

EFFECTIVE DATE
This Notice is effective September 19, 2013.

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