Mendota Community Hospital
Supplement to - Notice of Privacy Practices

Effective Date of Notice: February 1, 2005

Click here to view Notice of Privacy Practices

This is a supplement to the Notice that describes how medical information about you may be used and disclosed and how you can get access to this information. This supplement provides additional information for the following elements of the Notice:

	Your Rights as a Patient
	Examples of How Your Protected Health Information is Used or Disclosed
	Uses and Disclosures With Your Authorization
	Special Circumstances Where Your Authorization May Not Be Possible or Necessary

If you have any questions about the Notice or this supplement, please contact our Security Officer at Your Phone. Your Rights as a Patient:  Following is an additional explanation of your rights with respect to your protected health information and a brief description of how you may exercise these rights. Requesting a Restriction on Use or Disclosure: You have the right to request a restriction on the use or disclosure of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.
o You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
o The practice is not required to agree to a restriction that you may request. If we believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.
o If the practice does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Security Officer.

Access to Your Health Information: You have the right to inspect and copy your protected health information.

	To review or inspect your medical record or protected health information, please contact the Medical Records department.
	This right means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that the practice uses for making decisions about you.
	Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
	Depending on the circumstances, you may request that a decision to deny access be reviewed by an authorized person at the facility or by the Secretary of Health and Human Resources at the federal government. Please contact our Security Officer if you have questions about access to your office clinical or billing record.

Confidential Communications: You have the right to request to receive confidential communications from us by alternative means or at an alternative location. Please make this request in writing to our Security Officer.

	The practice will accommodate you if it is reasonable for your health care.
	We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.
	We will not request an explanation from you as to the basis for the request.

Amending Your Protected Health Information: You have the right to request an amendment to your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. Please contact the Security Officer if you wish to request an amendment to your medical record.

In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

An Accounting: You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. Please contact the Security Officer for assistance and instructions to receive an accounting Examples of How Your Protected Health Information is Used or Disclosed – Below are examples of how the practice may use or disclose protected health information as we provide you health care. The practice may contract with “Business Associates” to perform services. Whenever such arrangement occurs that involves the use or disclosure of your protected health information, the practice has a written contract that contains terms to safeguard the privacy of your protected health information. Note: These are examples and not complete lists of how your information is used or disclosed in your treatment, in payment, in operating the practice or in other activities as permitted by law.

Treatment: MCH uses and discloses your protected health information with the physicians, nurses, technicians, assistants, consultants, and any other related care giver or administrative service as we are providing or managing or coordinating you care, testing or treatment as an inpatient at a hospital or other facility, in another office or clinic or care center, or in our office.

	We may disclose your protected health information to a consulting physician who your primary care physician has called in to help with your treatment or diagnosis.
	We may disclose as necessary for continued care your protected health information to nursing homes or rehabilitation facilities if you are going to be admitted or considering admission.
	We may fax, make available or send your diagnostic or therapeutic test results, scans, films to another physician’s office involved in your care so that he or she knows about your condition as soon as reasonable.
	We may provide a copy of the information involved in your care to hospitals or facilities when considering an admission or transfer from a facility, and when you are admitted or transferred to a hospital or facility.
	We may notify you when we add services that relate to your health care.
	We may contract a specialist to read or interpret exam or scan results, or for a second opinion on a reading or interpretation.
	We may work with education programs allowing students to learn healthcare at our practice site, such as technician, nursing or medical programs.
	We may use or disclose your health information from a previous test at the office to assist care during a current treatment or regiment.

Payment: The practice uses and discloses your protected health information, as needed, to obtain payment for your health care services.

	We may disclose your protected health information to a managed care organization that is used by your insurance carrier for reviewing services provided to you for medical necessity.
	We may use a service to check eligibility or coverage for insurance benefits.
	We may process your claims through a service such as a billing service or a clearinghouse
	We may use your protected health information in utilization management or review, or managed care activities.
	We may use a lock box or other mechanism for checks or electronic payment transfers on the bills or claims for your care
	We may contract with an individual or company to review claims to insurance carriers
	We may contract with an agency or company to collect bills or claims
	We may share your protected health information as necessary with another member of the treatment team so that they can bill for services when independent billing by that member is required, such as with your attending or consulting physician, a radiologist, a cardiac specialist, or a surgeon.

Healthcare Operations: MCH may use or disclose, as-needed, your protected health information in order to support our business activities or operations.

	We may use or disclosure, as appropriate your protected health information in marketing. For example, we may contact you if we start-up a new service or add a specialty to the practice that may be of benefit to you. If you do not want us to contact you in these situations, please contact our Security Officer at the number listed above.
	We may share your protected health information with a company or individual to perform various administrative activities such as copying services, document shredding, document storage, delivery service, transcription services.
	We may call your name when it’s your turn for care or services
	We may contract with or use an individual or company to assist on the maintenance of our health information systems.
	We may contract with or use an individual or company as a consultant to assist with or perform functions in the administration or management of the practice such as legal assistance, financial auditing, strategic planning, workforce recruitment, quality assurance, physician recruitment, contracting and regulatory compliance.
	We may use or disclose as appropriate your protected health information as part of a State survey or because the State requires that we use or disclose the information to an agency, institution, company or individual
	We may use or disclose as appropriate your protected health information to attorneys or legal firms, auditors, or financial institutions
	We may use or disclose as appropriate your protected health information as part of a federally required survey or because the federal government requires that we use or disclose the information to an agency, institution, company or individual
	We may use or disclose as appropriate your protected health information for certification or accreditation as a health care provider
	Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the federal law HIPAA Section 164.500 et. seq.

Uses and Disclosures With Your Authorization – MCH obtains 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.

Sending a copy of your medical record or Protected Health Information to Another: If you wish to have your records or protected health information sent to another physician, another clinic, a health care service, an attorney, a life insurance carrier, or anyone else, please contact the Medical Records Department. They will provide you the appropriate forms and assist you.

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. Sometimes if you are able, your agreement or consent is required.

Opportunity to Agree or Object: In some instances you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then the practice may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

	Emergencies: We may use or disclose your protected health information if you require emergency treatment but are unable (or an authorized person or member of your family is unable) to authorize us to use or disclose the information. If this happens, the practice shall try to obtain your authorization (or the authorization of an authorized person or member of your family) as soon as reasonably practicable after the delivery of treatment.
	Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
	Family Notification: We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.
	Disaster Relief: Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Without Consent or Authorization: We may use or disclose your protected health information in the following situations without your consent or authorization.

	Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
	Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
	Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
	Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
	Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
	Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
	Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
	Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Hospital’s premises) and it is likely that a crime has occurred.
	Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
	Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
	Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
	Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
	Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
	Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.