Elizabethtown Community Hospital
Notice of Privacy Practices
Effective Date: April 14th, 2003

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.

WHO WILL FOLLOW THIS NOTICE

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

• Any health care professional authorized to enter hospital 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.

• Elizabethtown Community Health Center and Westport Health Center will also follow this privacy notice.

• All these entities, sites and locations follow the terms in this notice. In addition, these sites may share medical information with each other for treatment, payment or hospital operations purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION:

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

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

We are required by law to:

• make sure that medical information that identifies you is kept private

• give you this notice of our legal duties and privacy practices with respect to medical information about you; and

• follow the terms of the notice that is currently posted

• receive written acknowledgement from you that we have given you our Notice of Privacy Practices

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we may use and disclose medical information about you . For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technologists, pharmacists, or other hospital personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for 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 dietician if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. 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 family members, clergy or others we use to provide services that are part of your care.

For Payment
We may use and disclose medical information about you so that 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 will need to give your health plan information about an emergency room visit so your health plan will reimburse us for the treatment you received. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your health plan will cover the treatment. For example, if we refer you to an eye specialist for an eye problem you are having we may need to contact your insurance company for an authorization to cover the referral.

For Hospital Operations
We may use and disclose medical information about you for hospital operations. These uses and disclosures are necessary to run the hospital and make sure all our patients receive quality care. For example, we may use medical information to review the treatment and services to check on the performance of our staff in caring for you. We may also combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain treatments are effective. We may disclose information to hospital personnel such as doctors, nurses, technicians, medical students and others for review and learning purposes. We may combine the medical information we have with medical 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 medical information so others may use it to study health care and health care delivery without learning who specific patients are.

Appointment Reminders
We may use and disclose medical information to contact you, as a reminder that you have an appointment for treatment or medical care at the hospital, or if you should be scheduling an appointment.

Treatment Alternatives
We may use and disclose medical 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 disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Fundraising Activities
We may use medical information about you to contact you in an effort to raise money for the hospital and its operations. We may disclose medical information to a foundation related to the hospital so that the foundation may contact you in raising money for the hospital. We only would release contact information, such as your name, address and telephone number and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify Hospital Administration in writing.

Hospital Directory
We may include certain limited information about you in the hospital directory while you are an inpatient at the hospital. This information may include your name, location in the hospital, your general condition (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 members of the clergy, such as a priest or pastor, even if they do not ask for you by name, unless you request that we do not release it. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.

Individuals Involved In Your Care or Payment for Your Care
We may release medical information about you 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 tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical 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 Required By Law
We will disclose medical information about you when required to do so by federal, state or local law. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot or other wounds; or when ordered in a judicial or administrative proceeding.

For Health Oversight Activities
We will provide information to assist the government for an investigation, audit, for licensure or inspection of our organization. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws. One example is when we are applying for mammography accreditation, we send two sets of patient films for review by the American College of Radiology, which is the accrediting agency. We are required to report to official agencies such as the State Health Department and professional review organizations. These reports are for quality of care reviews. These agencies must also keep the information given to them confidential.

To Avert a Serious Threat to Health or Safety
We may use and disclose medical 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 prevent the threat.

Organ and Tissue Donation
If you are an organ donor, we may release medical 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 medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority

Workers` Compensation
We may release medical information about you for workers` compensation or similar programs. These programs provide benefits for work- related injuries or illness.

Public Health Risks
We may disclose medical information about you for public health activities. These activities generally include the following:

• to prevent or control disease, injury, or disability

• to report births and deaths

• to report abuse or neglect

• to report reactions to medications or problems with products

• to notify people of recalls of products they may be using

• to a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

• to 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.

Lawsuits and Disputes
If you are involved in a lawsuit or dispute, we may release medical information about you in response to a court or administrative order. We may also disclose medical information about you 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 medical information if asked by a law enforcement official for the following reasons:

• in response to a court order, subpoena, warrant, summons or similar process

• limited information 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 medical 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 release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities
We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Inmates
If you are an inmate of a correctional institution or under custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be if 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) the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy
You have the right to inspect and copy medical 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 and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Health Information department.

• We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital will review your request and denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. If the request is denied, you have the right to have your request reviewed by the New York State Review Committee.

Right to Amend
If you feel that medical 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, your request must be made in writing and submitted to the Health Information 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

• not created by us, unless the person or entity that created the information is no longer available to make amendment

• not part of the medical information kept by or for the hospital

• not part of the information which you would be permitted to inspect and copy; or which is accurate and complete.

Right to Get a list of Disclosures We Have Made
You have the right to get a list of instances in which we have released your medical information. This list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment or health care operations, directly to you, your family or in our facility directory. This list will not include any disclosures to corrections or law enforcement personnel, or before April 14th, 2003.

To request a list or accounting or disclosures, you must submit your request in writing to the Health Information department. Your request should indicate in what form you would like the list (for example, on paper or electronically).

Right to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you in treatment, payment or hospital operations. You also have the right to request a limit on the medical 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 an emergency room visit 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.

To request restrictions, you must make your request in writing to the Health Information 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) what you want to limit, for example, disclosure to your spouse.

Right to 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 contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Health Information 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 a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

Paper copies of this notice are available in Outpatient Registration, Lab, X-Ray, Elizabethtown Community Health Center, Westport Health Center, Physical Therapy, and the Emergency Department.

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 medical 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 Outpatient Registration, ECH, WHC, Physical Therapy and the Emergency Department. The notice will contain on the first page in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or healthcare services as an inpatient or outpatient, we will offer you a copy of the current notice in effect if you have not received it.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the hospital and/or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, contact the Director of Quality, 518.873.6377. All complaints must be submitted in writing.

You will not be retaliated against for filing a complaint.

OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your authorization. You understand that we are unable to take back any disclosures we already made with your permission, and that we are required to retain our records of the care that we provided to you.

If you have any questions about this notice, please contact:

Director of Quality
Elizabethtown Community Hospital
Park Street, P.O. Box 277
Elizabethtown, NY 12932
Phone: 518.873.6377