810 North 22nd Street
Blair, Ne 68008
Hospital Main Phone Number:
All Memorial Community Hospital and Health System facilities and grounds are tobacco-free. Implementing a ban on tobacco use both indoors and outdoors is an important step toward providing the safest possible environment and improving the health of the people and the communities we serve.
Effective Date: November, 2012
This notice describes how medical information about you may be used and disclosed and how you can get access to your medical information.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Memorial Community Hospital & Health System (MCH&HS) is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records, both clinical and financial, regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
This notice provides you with the following important information:
The terms of this notice apply to all records containing your identifiable health information that are created or retained by MCH&HS.We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records that MCH&HS has created or maintained in the past, and for any of your records we may create or maintain in the future. We will post a copy of our current notice in each of our facilities in a prominent location, and you may request a copy of our most current notice during any visit. We will also keep posted our current notice on MCH&HS web site, www.mchhs.org. The effective date of our notice is indicated at the beginning of this document.
This notice describes the privacy practices of the entities that are part of MCH&HS, including:
We may use health information about you to provide you with health treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at one of the MCH&HS hospitals or clinics. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell a MCH&HS dietitian if you have diabetes so that appropriate meals can be arranged. MCH&HS may share health information about you with others in order to coordinate the different things you need, such as prescriptions, lab work, x-rays and follow-up care. To the extent permitted by law, we also may disclose health information about you to people outside MCH&HS who may be involved in your health care (such as family members, home health agencies and others that provide services that are part of your care). Additionally, MCH&HS participates in regional health information exchanges, which enable the sharing of your health information in electronic form with other providers and facilities for treatment purposes.
We may use and disclose health information about you so that the treatment and services you receive from us may both be billed to and payment collected from you, and/or insurance company or a third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We also may disclose your health information to other health care providers and health plans for the payment activities of those providers and plans. For example, we may provide your information to a physician who is not on our medical staff so that the physician may bill you or your insurer for the services you received from that physician.
MCH&HS may use and disclose health information about you for administrative and operational purposes. These uses and disclosures are necessary for our operations, and to make sure that all of our patients receive quality care. For example, we may use your health information to review our treatment and services and to evaluate our performance in caring for you. This may include sharing your information with organizations that conduct patient surveys for MCH&HS. We may combine health information about some or all of our patients to decide what additional services we should offer, what services may not be needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and our personnel for review and learning purposes. We may also combine the health information we have with health information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are. We also may disclose your health information to certain other individuals and organizations, including physicians, hospitals and health plans, to assist with certain health care operations activities of these individuals and organizations. Except for those individuals and organizations described in the section of this Notice entitled “Who WillFollow This Notice,” these individuals and organizations either have or had in the past a relationship with you. The information we disclose about you will relate to this relationship. For example, we may disclose your health information to a hospital that is not affiliated with MCH&HS if that hospital has treated you in the past, the information we disclose relates to that relationship, and the hospital intends to use your information for its quality assurance and improvement activities. Similarly, we may share your health information with your health plan for quality assurance and improvement purposes. These are but some of the various permissible uses and disclosures MCH&HS may engage in as part of routine health care operations.
We may provide health information to entities who provide services for MCH&HS. We require these business associates to protect the health information we provide to them. For example, we may disclose name, phone number, address, zip code, age, gender, payer, dates, types, locations, and providers of service to companies that conduct patient satisfaction surveys on our behalf. These companies measure patient satisfaction through phone surveys following doctors’ appointments, outpatient procedures, and inpatient hospital stays. All business associates maintain a Business Associates Agreement with MCH&HS that require these companies and all of their staff to maintain full security and confidentiality of all information shared.
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.
We may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose your health information to tell you about health-related benefits or services that may be of interest to you.
We may disclose demographic information to the MCH&HS Foundation in order to raise money for MCH&HS and its operations, MCH&HS will only release contact information, such as your name, address and phone number and the dates you received treatment for services at MCH&HS. If you do not want MCH&HS to contact you for fundraising efforts, please notify the MCH&HS Marketing Department at (402) 426-2182.
We may include certain limited information about you in our patient/client directory while you are receiving treatment at MCH&HS. This information may include your name, location in the facility, 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 rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in MCH&HS and generally know how you are doing. If you do not want your information included in MCH&HS’s directory, upon your admission you should inform the personnel registering you into this facility. You may also tell your MCH&HS caregiver who will assist in communicating your wishes to the appropriate registration personnel NOTE: MCH&HS will strive to comply with requests for restrictions to disclosure of this general information. However, MCH&HS cannot ensure complete success.
We may release your health information to a friend or family member that is helping you pay for your health care, or who assists in taking care of you. We also may tell your family or friends your condition and that you are a patient at MCH&HS. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. As part of our spiritual commitment to both patients and their friends and family members, we may use your health information to engage in bereavement-related services, such as notifying family members of memorial services sponsored by MCH&HS for our patients who have passed away. If you do not want your information to be used for bereavement-related services, upon your admission you should inform the personnel registering you into this MCH&HS facility or your caregiver. If you have specific objections or instructions regarding these communications, you may discuss them with your caregivers.
We will use and disclose your health information when we are required to do so by federal, state or local law.
The following categories describe circumstances in which we may use or disclose your identifiable health information:
We may disclose health information about you for state and federal public health activities. These activities generally include the following:
We may disclose your health information to state or federal health oversight agency for activities authorized by law. These oversight activities include, for example, investigations, inspections, audits, surveys; licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We also may disclose your health information in response to a subpoena, discovery request, or other lawful process by another party involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about our patients to funeral directors as necessary to carry out their duties.
If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
We may use and disclose health information about you for research purposes in certain limited circumstances. For example, a research project may involve comparing the health of all patients who received one medication to those who received another, for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients’ need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, however, we may disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave our premises. We may disclose health information about you to a researcher if an Institutional Review Board or Privacy Board approves the researcher’s access to your health information without your authorization.
We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat and/or to any specifically identified victims of the threat.
If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
We may disclose your health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official. Disclosure for these purposes would be necessary: (1) for the institution to provide health care services to you; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
MCH&HS will obtain your written authorization prior to using or disclosing your health information for marketing purposes, however, marketing materials can be provided to you in a face-to-face encounter without obtaining your written authorization. MCH&HS may also communicate with you about products or services relating to your treatment, case management, or care coordination, or alternative treatment, therapies, providers or care settings without your written authorization. MCH&HS will disclose to you if we receive payment from or on behalf of a third party whose products or services are being described to you.
You have the following rights regarding the identifiable health information we maintain about you and in most cases MCH&HS has a form that may be completed to exercise the following rights
You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you at work or by U.S. Mail. To request that we contact you in a certain way or at a certain location, you must make your request in writing to the Administrator at 810 N. 22nd Street, Blair, NE, 68008. We will not ask you the reason for your request, and we will accommodate reasonable requests.
Your written request must specify how or where you wish to be contacted. You must provide us with a mailing address where you can receive correspondence and other communications from us related to payment for the services you have received from us. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
You have the right to request a restriction in our use or disclosure of your health information for treatment, payment or healthcare operations purposes. You also have the right to request that we limit our disclosure of your health information to individuals involved in your care or the payment for your care, such as family members and friends. Memorial Community Hospital & Health System is not required to agree to your request. NOTE: If we do agree, we will strive to comply with your request unless your information is needed to provide emergency treatment to you. However, MCH&HS cannot ensure complete success. MCH&HS will strive to honor any request that we not share information with your insurance company regarding care that you have paid for in full, out-of-pocket.
To formally request a restriction, you must make your request in writing to the Administrator at 810 N. 22nd St. Blair, NE. 68008. In your request, you must describe in a clear and concise fashion: (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, for example, disclosures to your spouse. MCH&HS does not have the authority to bind anyone else to any restrictions to which MCH&HS may agree.
You have the right to inspect and copy health information that may be used to make decisions about your care, including your medical records and billing records, but not including psychotherapy notes. MCH&HS will respond to your request within thirty (30) days, unless state law requires us to respond earlier.
To formally inspect or obtain a copy of health information that is maintained by or on behalf of MCH&HS and that may be used to make decisions about you, you must submit your request in writing to the Medical Record Custodian at 810 N. 22nd St. Blair, NE. 68008. MCH&HS may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy your health information under certain limited circumstances. For example, you may not be provided with your health information if it is determined that providing such information could cause harm to you or another person. In most cases, if you are denied access to health information you may request that the denial be reviewed. MCH&HS President of the Medical Staff, in accordance with applicable law, will review your request and the denial. The person conducting the review will not be the person who denied your request. MCH&HS will comply with the Medical Staff President’s recommendation.
If you feel that health information MCH&HS has 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 MCH&HS.
To formally request an amendment of health information that is maintained by or on behalf of MCH&HS about you, your request must be made in writing and submitted to the Medical Record Custodian at 810 N. 22nd St. Blair, NE. 68008. In addition, you must provide a reason that supports your request.
MCH&HS 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, MCH&HS may deny your request if you ask to amend information that:
You have the right to request an “accounting of disclosures.” An accounting of disclosures is a list of certain disclosures MCH&HS has made of your identifiable health information. To request an accounting of disclosures made by MCH&HS, you must submit your request in writing to the Medical Record Custodian at 810 N. 22nd St. Blair, NE. 68008. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically) The first list you request within a 12-month period will be free. For additional lists, you may be charged for the costs of providing the list. You will be notified of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Medical Records Custodian at 810 N. 22nd St. Blair, NE. 68008. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may obtain a copy of this notice at the following website: www.mchhs.org
If you believe your privacy rights have been violated, you may file a complaint with the MCH&HS Hospital Administrator at. 810 N. 22nd Street, Blair, NE, 68008. You may also file a complaint with the MCH&HS Quality Department at 810 N. 22nd Street, Blair, NE, 68008. You may also submit a complaint to:
Office for Civil Rights, Department of Health & Human Services
601 East 12th Street, Room 248
Kansas City, MO 64106
(816) 426-7065 (TDD)
(816) 426-3686 (Fax)
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note, we are required to retain records of your medical care.