Memorial Hospital Privacy Policy

Notice of Privacy Practices

FEDERALLY-REQUIRED NOTICE OF PRIVACY PRACTICES

THIS FEDERALLY-REQUIRED NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

WHO WE ARE

To comply with federal law, this Notice describes the privacy practices of, and applies to your protected health information generated by the employees and private independent physicians* practicing at:

Memorial Hospital includes:

Memorial Healthcare Centers
Memorial Outpatient Mental Health Services
Memorial Convalescent Center
Memorial Home Care

This applies to your protected health information generated, used, or disclosed by Memorial's employees or private independent physicians* who participate in an "Organized Health Care Arrangement" (OHCA) with Memorial. Memorial and private physicians* in the OHCA share protected health information with each other as necessary to carry out treatment, payment, and health care operations related to the OHCA and your care and treatment at Memorial. Your private physicians* may have different policies or notices regarding use and disclosure ofyour protected health information created in their private offices or clinic practices.

This "Organized Health Care Arrangement" applies only to federal privacy requirements regarding your protected health information. In all other respects, all physicians* practicing at Memorial and locations specified above are private independent practitioners and, as such, are not employees or agents of Memorial. These independent practitioners, and not Memorial, make the independent treatment decisions and professional medical/clinical judgements about the care and services you receive. Understandably, Memorial does not control and is not responsible for these treatment decisions.

*Includes private physicians, dentists, podiatrists, and all other allied health practitioners appointed to the Medical Staff of Memorial.

OUR PRIVACY OBLIGATIONS

We are required by law to maintain the privacy of your protected health information ("PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to your PHI. When we use or disclose your PHI, we are required to abide by the terms of this Notice (or the notice in effect at the time of the use or disclosure).

PERMISSIBLE USES AND DISCLOSURES WITHOUT YOUR WRITTEN AUTHORIZATION

In certain situations, described below, we must obtain your written authorization to use and/or disclose your PHI. However, unless otherwise specified by Federal or Illinois law, or Memorial policy, we do not need any type of authorization from you for the following uses and disclosures:

For Treatment
We may use and disclose your PHI to provide treatment and other services to you-for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose PHI to other health care providers involved in your treatment.

For Payment
We may use and disclose your PHI to obtain payment for services that we provide to you-for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, PPO, HMO, or other company or program that arranges or pays for some or all of your health care costs. We may also disclose your PHI to another covered entity in order for them to bill for services you received at Memorial.

For Health Care Operations
We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may also disclose PHI to Memorial's Patient Care Coordinator in order to resolve any complaints you may have.

We may also disclose PHI to your physicians and the specialists selected by them as well as other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct health care operations such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance. We may disclose and discuss your PHI during and after you receive services with physicians and other health care providers as well as Memorial's employees including all aspects of your condition, treatment and content of your medical records with Memorial's management and staff employees as well as Memorial's authorized representatives for various specific purposes such as, quality assurance, utilization review, legal, accreditation, licensure, etc. These disclosures and subsequent discussions of your PHI are for quality improvement, hospital management, utilization review, risk management, litigation defense evaluation and preparation, complaint resolution, and other operational purposes.

Appointment Reminders and Call Backs
We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment at Memorial. We may also use information to contact you following a procedure so as to verify your recovery.

Use or Disclosure for Directory of Individuals at Memorial Hospital or Memorial Convalescent Center
We may include your name, location in Memorial Hospital or Memorial Convalescent Center, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name or to members of the clergy, provided, however, that religious affiliation will only be disclosed to members of the clergy.

Disclosure to Individuals Involved in Your Care or Payment for Your Care
Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care, if that information is relative to your care. We may also give information to someone who helps pay for your care. We may provide information to family members, physicians, clergy or others that are involved in your medical care. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at the hospital. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as physicians, family members, clergy, or others we use to provide services that are part of your care.

Fund Raising Communications
We may contact you to request a tax-deductible charitable contribution to assist Memorial in continuing its mission of providing high-quality and cost-effective services to the residents of Southwest Illinois. In connection with any fund raising, we may disclose to our Foundation office without your written authorization, demographic information about you (i.e. - name, address, and phone number) and dates on which we provided health care services to you. If you do not wish to receive future fund raising materials, please write to Memorial Foundation, Inc., 4500 Memorial Drive, Belleville, Illinois 62226. In the event that you contact us with this request, all reasonable efforts will be taken to ensure that you will not receive any fund raising communications from us in the future.

Public Health Activities
We may disclose your PHI for the following public health activities: to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; to report child abuse and neglect to the Illinois Department of Children and Family Services or other government authorities authorized by law to receive such reports; to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and other public health activities that are required by law.

Victims of Abuse, Neglect or Domestic Violence
If we reasonably believe you are a victim of abuse, neglect, or domestic violence, we may disclose your PHI to the Illinois Department of Children and Family Services, the Illinois Department of Human Services or other governmental authority, including social service or protective services agencies, authorized by law to receive reports of such abuse, neglect, or domestic violence.

Health Oversight Activities
We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

Judicial and Administrative Proceedings
We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Officials
We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or grand jury or administrative subpoena.

Decedents
We may disclose your PHI to a coroner, medical examiner or funeral home as authorized by law.

Organ and Tissue Procurement
We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

Research
We may use or disclose your PHI to researchers when their research has been approved by the Belleville Community Institutional Review Board.

Health or Safety
We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person's or the public's health or safety.

Specialized Government Functions
We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State, under certain circumstances.

Workers' Compensation
We may disclose your PHI as authorized by, and to the extent necessary to comply with, state law relating to workers' compensation or other similar programs.

As required by law
We may use and disclose your PHI when required to do so by any other federal or state law or regulation listed in the preceding categories.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

Use or Disclosure with Your Authorization
For any purpose other than the ones described above, we only may use or disclose your PHI when you grant us your written authorization. For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing you in litigation in which you are involved.

Marketing
We must obtain your written authorization prior to using your PHI to send you any marketing materials. We can, however, provide you with marketing materials in a face-to-face encounter without obtaining your marketing authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining your marketing authorization. In addition, we may communicate with you about products or services relating to your treatment, case management, care coordination, alternative treatments, therapies, providers or care settings without your marketing authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Right to Inspect and Copy Your Health Information
You may request access to your Memorial designated record set in order to inspect and/or request copies of the records. Under limited circumstances, we may deny you access to all or a portion of your records. All requests for access must be made in writing. If you desire access to your records, please obtain a Record Access Form from the Medical Record Department and submit the completed form to the Medical Record Department. If you request copies for non-medical or non-payment related reasons, we will charge you reasonable duplication fees.

Right to Request Additional Restrictions
You may request restrictions on our use and disclosure of your PHI for: treatment, payment and health care operations; to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care; or to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office (see address and phone number at the end of this Notice). We will send you a written response.

Right to Receive Confidential Communications
You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

Right to Revoke Your Authorization
You may revoke your authorization except to the extent that we have taken action in reliance upon it. You may obtain a Revocation Authorization form by contacting the Privacy Office (see address and phone number at the end of this Notice).

Right to Amend Your Records
You have the right to request that we amend PHI maintained in your Memorial designated record set. Amendment requests must be submitted in writing and clearly identify the information to be amended, as well as the reasons for the amendment. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information to be amended is accurate and complete or other special circumstances apply. In the case of a requested amendment concerning the treatment of a mental illness or developmental disability, you have the right to appeal our decision not to amend your PHI to an Illinois court.

Right to Receive an Accounting of Disclosures
Upon your written request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged a reasonable cost-based fee.

For Further Information and Complaints
If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Office (see Privacy Office address below). You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us, or the Director.

Right to Receive Paper Copy of this Notice
Notices will be available in each of our registration areas for you to read and/or take a copy. Also, upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.

Effective Date
This Notice is effective on April 14, 2003.

Right to Change Terms of this Notice
We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in registration areas around Memorial Hospital, Memorial Convalescent Center, Memorial Healthcare Centers, Memorial Outpatient Mental Health Services (including all on- and off-campus satellite offices) and on our Internet site at www.memhosp.com. You also may obtain any new notice by contacting the Privacy Office at:

Privacy Office
c/o Medical Records Department
4500 Memorial Drive
Belleville, IL 62226
Telephone Number: (618) 257-5335

4/14/03

Memorial Hospital
4500 Memorial Drive, Belleville IL 62226
(618) 233-7750 • info@memhosp.com copyright 2008

Notice of Privacy Practices FEDERALLY-REQUIRED NOTICE OF PRIVACY PRACTICES THIS FEDERALLY-REQUIRED NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. WHO WE ARE To comply with federal law, this Notice describes the privacy practices of, and applies to your protected health information generated by the employees and private independent physicians* practicing at: Memorial Hospital includes: on- and off-campus satellite offices Memorial Healthcare Centers Memorial Outpatient Mental Health Services Memorial Convalescent Center Memorial Home Care This applies to your protected health information generated, used, or disclosed by Memorial's employees or private independent physicians* who participate in an "Organized Health Care Arrangement" (OHCA) with Memorial. Memorial and private physicians* in the OHCA share protected health information with each other as necessary to carry out treatment, payment, and health care operations related to the OHCA and your care and treatment at Memorial. Your private physicians* may have different policies or notices regarding use and disclosure ofyour protected health information created in their private offices or clinic practices. This "Organized Health Care Arrangement" applies only to federal privacy requirements regarding your protected health information. In all other respects, all physicians* practicing at Memorial and locations specified above are private independent practitioners and, as such, are not employees or agents of Memorial. These independent practitioners, and not Memorial, make the independent treatment decisions and professional medical/clinical judgements about the care and services you receive. Understandably, Memorial does not control and is not responsible for these treatment decisions. Includes private physicians, dentists, podiatrists, and all other allied health practitioners appointed to the Medical Staff of Memorial. OUR PRIVACY OBLIGATIONS* We are required by law to maintain the privacy of your protected health information ("PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to your PHI. When we use or disclose your PHI, we are required to abide by the terms of this Notice (or the notice in effect at the time of the use or disclosure). PERMISSIBLE USES AND DISCLOSURES WITHOUT YOUR WRITTEN AUTHORIZATION In certain situations, described below, we must obtain your written authorization to use and/or disclose your PHI. However, unless otherwise specified by Federal or Illinois law, or Memorial policy, we do not need any type of authorization from you for the following uses and disclosures: For Treatment We may use and disclose your PHI to provide treatment and other services to you-for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose PHI to other health care providers involved in your treatment. For Payment We may use and disclose your PHI to obtain payment for services that we provide to you-for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, PPO, HMO, or other company or program that arranges or pays for some or all of your health care costs. We may also disclose your PHI to another covered entity in order for them to bill for services you received at Memorial. For Health Care Operations We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may also disclose PHI to Memorial's Patient Care Coordinator in order to resolve any complaints you may have. We may also disclose PHI to your physicians and the specialists selected by them as well as other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct health care operations such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance. We may disclose and discuss your PHI during and after you receive services with physicians and other health care providers as well as Memorial's employees including all aspects of your condition, treatment and content of your medical records with Memorial's management and staff employees as well as Memorial's authorized representatives for various specific purposes such as, quality assurance, utilization review, legal, accreditation, licensure, etc. These disclosures and subsequent discussions of your PHI are for quality improvement, hospital management, utilization review, risk management, litigation defense evaluation and preparation, complaint resolution, and other operational purposes. Appointment Reminders and Call Backs We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment at Memorial. We may also use information to contact you following a procedure so as to verify your recovery. Use or Disclosure for Directory of Individuals at Memorial Hospital or Memorial Convalescent Center We may include your name, location in Memorial Hospital or Memorial Convalescent Center, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name or to members of the clergy, provided, however, that religious affiliation will only be disclosed to members of the clergy. Disclosure to Individuals Involved in Your Care or Payment for Your Care Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care, if that information is relative to your care. We may also give information to someone who helps pay for your care. We may provide information to family members, physicians, clergy or others that are involved in your medical care. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at the hospital. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as physicians, family members, clergy, or others we use to provide services that are part of your care. Fund Raising Communications We may contact you to request a tax-deductible charitable contribution to assist Memorial in continuing its mission of providing high-quality and cost-effective services to the residents of Southwest Illinois. In connection with any fund raising, we may disclose to our Foundation office without your written authorization, demographic information about you (i.e. - name, address, and phone number) and dates on which we provided health care services to you. If you do not wish to receive future fund raising materials, please write to Memorial Foundation, Inc., 4500 Memorial Drive, Belleville, Illinois 62226. In the event that you contact us with this request, all reasonable efforts will be taken to ensure that you will not receive any fund raising communications from us in the future. Public Health Activities We may disclose your PHI for the following public health activities: to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; to report child abuse and neglect to the Illinois Department of Children and Family Services or other government authorities authorized by law to receive such reports; to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and other public health activities that are required by law. Victims of Abuse, Neglect or Domestic Violence If we reasonably believe you are a victim of abuse, neglect, or domestic violence, we may disclose your PHI to the Illinois Department of Children and Family Services, the Illinois Department of Human Services or other governmental authority, including social service or protective services agencies, authorized by law to receive reports of such abuse, neglect, or domestic violence. Health Oversight Activities We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid. Judicial and Administrative Proceedings We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process. Law Enforcement Officials We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or grand jury or administrative subpoena. Decedents We may disclose your PHI to a coroner, medical examiner or funeral home as authorized by law. Organ and Tissue Procurement We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation. Research We may use or disclose your PHI to researchers when their research has been approved by the Belleville Community Institutional Review Board. Health or Safety We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person's or the public's health or safety. Specialized Government Functions We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State, under certain circumstances. Workers' Compensation We may disclose your PHI as authorized by, and to the extent necessary to comply with, state law relating to workers' compensation or other similar programs. As required by law We may use and disclose your PHI when required to do so by any other federal or state law or regulation listed in the preceding categories. USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION Use or Disclosure with Your Authorization For any purpose other than the ones described above, we only may use or disclose your PHI when you grant us your written authorization. For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing you in litigation in which you are involved. Marketing We must obtain your written authorization prior to using your PHI to send you any marketing materials. We can, however, provide you with marketing materials in a face-to-face encounter without obtaining your marketing authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining your marketing authorization. In addition, we may communicate with you about products or services relating to your treatment, case management, care coordination, alternative treatments, therapies, providers or care settings without your marketing authorization. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION Right to Inspect and Copy Your Health Information You may request access to your Memorial designated record set in order to inspect and/or request copies of the records. Under limited circumstances, we may deny you access to all or a portion of your records. All requests for access must be made in writing. If you desire access to your records, please obtain a Record Access Form from the Medical Record Department and submit the completed form to the Medical Record Department. If you request copies for non-medical or non-payment related reasons, we will charge you reasonable duplication fees. Right to Request Additional Restrictions You may request restrictions on our use and disclosure of your PHI for: treatment, payment and health care operations; to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care; or to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office (see address and phone number at the end of this Notice). We will send you a written response. Right to Receive Confidential Communications You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations. Right to Revoke Your Authorization You may revoke your authorization except to the extent that we have taken action in reliance upon it. You may obtain a Revocation Authorization form by contacting the Privacy Office (see address and phone number at the end of this Notice). Right to Amend Your Records You have the right to request that we amend PHI maintained in your Memorial designated record set. Amendment requests must be submitted in writing and clearly identify the information to be amended, as well as the reasons for the amendment. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information to be amended is accurate and complete or other special circumstances apply. In the case of a requested amendment concerning the treatment of a mental illness or developmental disability, you have the right to appeal our decision not to amend your PHI to an Illinois court. Right to Receive an Accounting of Disclosures Upon your written request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged a reasonable cost-based fee. For Further Information and Complaints If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Office (see Privacy Office address below). You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us, or the Director. Right to Receive Paper Copy of this Notice Notices will be available in each of our registration areas for you to read and/or take a copy. Also, upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically. Effective Date This Notice is effective on April 14, 2003. Right to Change Terms of this Notice We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in registration areas around Memorial Hospital, Memorial Convalescent Center, Memorial Healthcare Centers, Memorial Outpatient Mental Health Services (including all on- and off-campus satellite offices) and on our Internet site at www.memhosp.com. You also may obtain any new notice by contacting the Privacy Office at: Privacy Office c/o Medical Records Department 4500 Memorial Drive Belleville, IL 62226 Telephone Number: (618) 257-5335 4/14/03
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