Mendota Community Hospital
Notice of Privacy Practices

Effective: February 1, 2005

Click here to view Additional Supplement to Notice of Privacy Practice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Please review it carefully!

Our facility is required by law to provide you with this Notice of its legal duties and privacy practices with respect to protected health information. This Notice explains how we use and disclose health information - for your treatment and care, for payment of your health care, to operate the facility, and for other purposes that are permitted by Illinois or by federal law. Additional detail describing or explaining the elements in this Notice is readily accessible at the admissions desk or in the hospital lobby. If you have any questions about this Notice, please contact our Security Officer at 815-539-7461.

Your Rights as a Patient - You have a right to the privacy of health information that contains information that may identify you. This “protected” information may include demographic information such as your phone number or address. It may relate to your past, present or future physical or mental health or condition, and related health care services. You have the right to -

	Request restrictions on certain uses and disclosures of your protected information. The facility may not be able to agree to the restriction because restricting the information may harmfully affect your health care, payment for your healthcare, or some other aspect of your health care.
	Receive confidential communications where reasonable
	Inspect and copy your protected health information, according to policy
	Amend your protected health information, according to policy
	Receive an accounting of your protected health information, according to policy
	Receive a paper copy of this Notice or of any previous notice by contacting our facility manager

Complaints: If you believe that we have violated your health information privacy rights, you may complain to our Security Officer or to the Secretary of Health and Human Resources at the federal government. If you wish to file a complaint, please contact our Security Officer for assistance. The facility will not retaliate in any fashion for filing a complaint. The Facility’s Duties – MCH is required by law to maintain the privacy of your protected health information and to abide by the terms in this Notice. We may change this notice at any time as the law, our practices or our policies change. Any new Notice will be effective for all protected health information that we maintain at the time of the Notice. Examples of How Your Protected Health Information is Used or Disclosed –The use or disclosure of your protected health information by MCH is described by, but not limited to, the following examples including involvement of a business associate of the practice. See the Notice Supplement for additional detail if desired. Treatment: We use and disclose your protected health information with the physicians, nurses, technicians, assistants, consultants, students and any other related care giver or administrative service as we are providing or managing or coordinating your care. In certain cases for your safety and for quality health care, your name may be placed on a door, a file, a board, a drawer or cabinet, a container, or a sign-in sheet. Often family or friends contact us asking about a patient’s condition. If you do not wish certain members of your family or acquaintances to know of the your care or your condition, please let us know so that we can reasonably protect your privacy. Payment: We use and disclose your protected health information, as needed, to obtain payment for your health care services including processing charges, claims and payments; eligibility or coverage verification; managed care and utilization management activities. Healthcare Operations: We may use or disclose as needed your protected health information in order to support our business activities including budgeting and financial management, marketing, quality assurance, management and training of our workforce, credentialing of our physician staff members for contracting or other business related activities. Uses and Disclosures With Your Authorization – We obtain your written authorization for other uses and disclosures of your protected health information, unless otherwise permitted or required by law. You may revoke your authorization, at any time in writing, except to the extent that we have taken an action in reliance on your authorization. See additional detail if desired. Special Circumstances Where Your Authorization May Not Be Possible or Necessary – There are special circumstances described in law where your protected health information may be used or disclosed without your authorization or consent. See additional detail if desired.

Note: As stated earlier, additional detail describing or explaining the elements in this Notice is readily accessible at the admissions desk or the hospital lobby. If you have any questions about this Notice, please contact our Security Officer at 815-539-7461.