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Privacy Notice

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Effective Date: September 23, 2013

Kirby Medical Center
1000 Medical Center Drive Monticello, IL 61856

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 or privacy concerns, please contact the Corporate Compliance & HIPAA Privacy Office at (217) 762--1506

WHO WILL FOLLOW THIS NOTICE:

This notice describes our hospital’s practices and that of:

  • Any health care professional authorized to enter information into your hospital chart.
  • All departments and units of the hospital.
  • Any member of a volunteer group we allow to help you while you are in the hospital.
  • All employees, staff and other hospital personnel.
  • The Kirby Medical Group and the Kirby Ambulance Service. 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 hospital operations purposes described in this notice.
  • Those providers with whom we have an Organized Health Care Arrangement (OHCA).

OUR PLEDGE REGARDING HEALTH INFORMATION

We understand that your health information and your health are personal. We are committed to protecting your health information. We create a record of the care and services you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your health information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose your health information. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:

  • Make sure that health information which identifies you is kept private;
  • Give you this notice of our legal duties and privacy practices with respect to your health information;
  • Follow the terms of the notice that is currently in effect; and
  • To notify you following a breach of unsecured protected health information.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION.

We may use your health information and disclose it to appropriate persons, authorities and agencies, as allowed by federal and state law. We may do this without your written authorization for the following purposes:

  • For Treatment We may use or disclose your health information to healthcare providers within Kirby or outside of Kirby in order for such healthcare providers to provide you with treatment or services. 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 the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share your health information in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose your health information to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy or others we use to provide services that are part of your care.
  • For Payment We may use and disclose your health information so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also 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.
  • For Health Care Operations We may use and disclose your health information for hospital operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. We may also combine our health information with health information from other hospitals 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 healthcare and healthcare delivery without learning who the specific patients are.
  • Appointment Reminders We may use and disclose 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 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 health information to tell you about health-related benefits or services 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. If you do not want the hospital to contact you for fund raising efforts, you must notify the Kirby Medical Center Foundation in writing at the address provided in this notice or by phone at (217) 762-1509.
  • Hospital Directory We may include certain limited information about you in the hospital directory while you are a patient at the hospital. 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 rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. You have the right to request a restriction or limitation on the information we use or disclose about you. Please see the “Right to Restrictions” paragraph below.
  • Individuals Involved in Your Care or Payment for Your Care We may release your health information to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell those involved in your care, such as family or friends, your condition and that you are in the hospital. In addition, we may disclose your health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
  • Research Under certain circumstances, we may use and disclose your health information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, 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, but we may, however, disclose your health information to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the health information they review does not leave the hospital. We will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.
  • As Required By Law We will disclose your health information when required to do so by federal, state or local law.
  • To Avert a Serious Threat to Health or Safety We may use and disclose your health information 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.

SPECIAL SITUATIONS

  • Organized Health Care Arrangement We are a clinically integrated care setting where patients receive care from our personnel and from independent doctors and other practitioners who provide care to our patients (collectively called “practitioners”). We and these practitioners need to share health information freely to provide care to patients, and to conduct our healthcare operations. Therefore, we and the practitioners have agreed to follow uniform information practices when using or disclosing health information related to inpatient or outpatient hospital services. This arrangement is called an “Organized Healthcare Arrangement” and only covers information practices for services rendered through us. It does not cover the information practices of the practitioners in their office or at other care settings. It does not alter our independent status and the practitioners or make them jointly responsible for the clinical services provided.
  • Organ and Tissue Donation 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.
  • Military and Veterans If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
  • Workers' Compensation We may release your health information as required by workers' compensation laws or similar programs. These programs provide benefits for work-related injuries or illness.
  • Public Health Risks We may disclose your health information for public health activities. These activities generally include the following:
    • To prevent or control disease, injury or disability;
    • To report births or and deaths;
    • To report child abuse and 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 this disclosure if you agree or when required or authorized by law.
  • Health Oversight Activities We may disclose health information to a health oversight agency 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 healthcare system, government programs, and compliance with civil rights laws.
  • Lawsuits and Disputes If you are involved in a lawsuit or a dispute, 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 the dispute, but only if efforts have been made to tell you about 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, such as:
    • 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 the hospital; and
    • 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.
  • Coroners, Medical Examiners and Funeral Directors 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 patients of the hospital to funeral directors as necessary to carry out their duties.
  • National Security and Intelligence Activities We may release health 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 your information to authorized federal officials so they may provide protection to the President of the United States, other authorized persons or foreign heads of state or conduct special investigations.
  • Correctional Institutions If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (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.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. Specific examples of uses and disclosures of medical information requiring your permission include:

  • Most uses and disclosures of psychotherapy notes (private notes of mental health professional kept separately from a medical record);
  • Most uses and disclosures of your medical information for marketing purposes;
  • Disclosures of your medical information that constitute the sale of your medical information.

If you provide us permission to use or disclose your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.

Although your medical information is our property, you have the right to:

  • Inspect and Copy You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect or copy health information that may be used to make decisions about you, you must complete a form which can be obtained from the Health Information Management department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. If we maintain your health information in an electronic health record, you have the right to request that we provide you, or another person designated by you, with a copy of your health information in electronic format. We will not charge you a fee that is greater than our labor costs to respond to your request for your health information in an electronic format.

We may deny your request to inspect or copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital 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 review.

  • Amend Your Health Information If you feel that health information we have 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 hospital.

To request an amendment, you must complete a special form from the Health Information Management 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 the hospital;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

If your request for amendment is denied, we will provide you with a written explanation for the denial. Following a denial, you may submit a written statement disagreeing with the denial, which will be included in your record.

  • Request An Accounting of Disclosures You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of your health information. The list will not include disclosures we have made for treatment, payment and healthcare operations purposes (with certain exceptions related to health information in electronic health records), those made directly to you or under an authorization that you provided, or those made to your family or friends. Neither will the list include disclosures we have made for national security purposed or to law enforcement personnel, or disclosures made before April 14, 2003.

To request this list or accounting of disclosures, you must submit your request in writing on a form available in the Health Information Management department. Your request must state a time period, which 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 or electronically). The first list you request within a 12¬ month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

  • Request Restrictions You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. However, we will honor your request to restrict our disclosures of your health information to a health insurance plan for payment or healthcare operations purposes if the health information pertains solely to services you have paid for out¬ of¬ pocket, in full, and unless the disclosure is required by law or is determined to be for treatment purposes.

To request restrictions, you must make your request in writing on a form available in the Health Information Management 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 - for example, disclosures to your spouse.

  • Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing on a form that is available in the Health Information Management department. We will not ask you the reason for the request and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
  • A Paper Copy of This Notice You have the right to a paper copy of this notice at any time even if you have agreed to receive this notice electronically.

You may download a copy of this notice at our website: www.KirbyHealth.org.

Paper copies of this notice are available at the hospital Registration Desk.

  • Receive Notice of a Breach You have the right to be notified in writing following a breach of your medical information that is not secured in accordance with certain security standards.

CHANGES TO THIS NOTICE

  • We reserve the right to change this notice We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the hospital and it will be available for you to take with you. The notice will contain on the first page, in the top right-hand corner, the effective date.

CONCERNS OR COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, please contact the Corporate Compliance & HIPAA Privacy Office in writing at the address below or by telephone at (217) 762-1506.

Kirby Medical Center
1000 Medical Center Dr.
Monticello, IL 61856

You will not be penalized for filing a complaint.

Approved by:

Craig Webb,
Chairman, Hospital Board of Directors

Steven D. Tenhouse,
Chief Executive Officer