Notice of Privacy Practices Effective Date: April 7, 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. If you have any questions about this Notice, our policies, or practices please contact the Women & Children's Hospital Privacy Officer at 337-475-4134. Who Will Follow This Notice This Notice describes our organization’s practices and those of: Health care professionals who are members of our workforce authorized to access and/or enter information into your medical record or billing record. All departments and units of this facility. All employees, volunteers and other facility personnel considered a part of our workforce. Any health care entities and medical offices owned by or affiliated with this facility. This facility is a part of an organized health care arrangement (OHCA). An OHCA is (i) a clinically integrated setting in which individuals typically receive health care from more than one health care provider or (ii) an organized system of health care in which more than one health care provider participates. The health care providers who participate in the OHCA will share medical and billing information about you with one another as may be necessary to carry out treatment, payment, and health care operations activities. This Notice of Privacy Practices constitutes the Notice of Privacy Practices for the OHCA and all the health care providers participating in the OHCA. The health care providers who participate in the OHCA and to which this Notice of Privacy Practices applies include this facility, the members of its medical staff. Certain physicians who provide medical service s in this facility are members of the facility’s medical staff and, as such, are part of the OHCA. Such physicians are, however, self-employed independent contractors; they are not the agents, servants, or employees of this facility, and the facility is not responsible for their judgment or conduct. Our Pledge Regarding Medical and Billing Information We understand that information about you and your health is personal. We are committed to protecting medical and billing information about you. We create a record of the care and services you receive at our facility. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and charges or bills for services related to your care. These records are used 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 facility, whether made by facility personnel or your personal care provider. Your personal care provider (for example, your personal physician, midwife, etc.) may have different policies or Notices regarding the provider’s use and disclosure of your medical and billing information created in the practice office or clinic. This Notice will tell you about the ways in which we may use and disclose medical and billing information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information. We are required by law to: Make sure that medical and billing information that identifies you is kept private; Give you this Notice of our legal duties and privacy practices with respect to medical and billing information about you; and Follow the terms of the Notice that is currently in effect. How We May Use and Disclose Medical and Billing Information About You The following categories describe different ways we use and disclose medical and billing information. 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, health care technicians, health care professional students, or other facility personnel who are involved in taking care of you at our facility. We may also disclose information about you to other health care providers outside our facility so they may treat you. 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 we can arrange for appropriate meals. Different departments of the facility also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. This information is shared on the basis of other health care staff “needing to know” the information to provide safe necessary treatment to you. We also may disclose medical information about you to people outside the facility who may be involved in your medical care after you leave the facility, such as family members, or other health care professionals we use to provide services that are a part of your care. For Payment. We may use and disclose medical information about you so the treatment and services you receive at our facility may be billed to and payment may be collected from you, an insurance company, or other third party. For example, we may need to give your health plan information about surgery you received at our facility 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 pay for the treatment. This does NOT mean that all information in your medical record will be shared to gain approval or seek payment, but only that information which is necessary. We may also provide information about you to another health care provider or facility for their payment activities. For example, we may provide information about you to your doctor’s office so they can bill you or your insurance company. For Health Care Operations. We may use and disclose medical information about you for facility operations. These uses and disclosures are necessary to run the facility and make sure all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many facility patients to decide what additional services the facility should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, professional health care students, and other facility personnel for review and learning purposes. We may also combine the medical information we have with medical information from other facilities 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 you or other patients are as individuals. We may provide information about you to other health care providers, health plans, or health care clearinghouses to perform activities such as quality assessment, case management, training, and studying groups of people for the purpose of improving health. Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for tests, treatment, or medical care. 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 or offer you optional care alternatives. Health-Related Products and Services. We may use and 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 facility and its operations. We may disclose medical information to a foundation related to the facility so that the foundation may contact you to raise money for the facility. In such event we would release contact information, such as your name, address and phone number, and the dates you received treatment or services at our facility. If you do not want the facility to contact you for fundraising efforts, you must notify the Director of Marketing in writing. Facility Directory. Unless you tell us otherwise, we may include certain limited information about you in the facility directory while you are a patient at the facility. This information may include your name, location in the facility, your general condition (such as ”fair”, “stable”, “critical”), 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 minister, priest or rabbi, even if they don’t ask for you by name. This disclosure is necessary so your family, friends, and clergy can visit you in the facility and generally know how you are doing. You have the right to request that you not be identified to any of these individuals upon admission. Individuals Involved in Your Care or Payment for Your Care. Unless you tell us otherwise, we may release medical information about you to a friend or family member who is involved in your medical care. We may give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the facility. In addition, we may disclose medical information about you to an entity assisting us in a disaster relief effort so that your family can be notified about your condition, status, and location. Business Associates. There are some services provided in our organization through contracts with business associates. Examples may include certain laboratory tests, medical transcription services, and a copy service we may use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associates so they can perform the jobs we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to safeguard your information appropriately. Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who receive one medication to those who received another, for the same condition. In certain circumstances, we are permitted to disclose medical information about you to people preparing for research. For example, researchers may look for patients with specific treatment needs to develop a research protocol, but may not remove the medical information they review from the facility. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will almost always 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 facility. As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local laws. To Avert a Serious Threat to Health or Safety. We may use or 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 other person. Any disclosure, however, would only be to someone able to help 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 Personnel. If you are a member of the armed forces, active or reserve, 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 as necessary to comply with laws related to workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses. 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 child abuse or 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 who may be a risk for contracting or spreading a disease or condition; and To notify the appropriate government or law enforcement 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 medical 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 health care 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 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 to do so by a law enforcement official: In response to a court order, subpoena, warrant, summons, or similar process; 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 facility; 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 also release medical information about you as a patient of the facility 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. Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, and foreign heads of state or to conduct special investigations. Inmates. If you are an inmate of a correctional institution or under the 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 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 medical information: authorization and right to revoke authorization. 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 authorization. If you authorize us to use or disclose medical information about you, you may revoke that authorization, 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 written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required by state law to retain our records of the care that we provide to you. Your Rights Regarding Medical and Billing Information About You You have the following rights regarding your medical and billing information we maintain. Right to Inspect and Copy Your Medical and Billing Information. 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 obtain a copy of medical and billing information that may be used to make decisions about you, you must submit your request in writing to Women & Children's Hospital Record Custodian, 4200 Nelson Road, Lake Charles, LA 70605. 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. We may deny your request to inspect and copy this information in certain limited circumstances. If you are denied access to medical or billing information, you may make a request, in writing to the Women & Children's Hospital Privacy Officer, that the denial be reviewed. Another licensed health care professional chosen by the facility 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. Right to Amend Your Medical and Billing Information. If you feel that medical and billing information we have about you is incorrect or incomplete, you may ask us to amend the information. You have a right to request an amendment for as long as the information is kept by or for the facility. To request an amendment, your request must be made in writing and submitted to the Women & Children's Hospital, Record Custodian, 4200 Nelson Road, Lake Charles, LA 70605. 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 medical or billing information kept by or for the facility; Is not part of the information that you would be permitted to inspect and copy; or Is accurate and complete. Right to an Accounting of Disclosures of Your Medical and Billing Information. You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical and billing information about you, except for those disclosures to carry out treatment, payment, or health care operations, disclosures made to you, disclosures you have authorized, or certain other disclosures. To request an accounting of disclosures, you must submit your request in writing to the Women & Children’s Privacy Officer. Your request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003. 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 costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the uses and disclosures of your medical or billing information for treatment, payment or health care operations. You also have the right to request a restriction on the medical or billing information we disclose about you to someone who is involved in your care or payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about your particular surgery or other particular treatment. We are not required to agree to your request. If we cannot agree to your requested restriction, we will notify you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. We may terminate our agreement for a restriction if we inform you and you agree. To request restrictions, you must make your request in writing to Women & Children's Hospital. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical treatment and options in a certain way or at a certain location. For example, you can ask that we contact you at a different phone number or address than that shown in your records. To request confidential communications, you must make your request in writing to the Privacy Officer, 4200 Nelson Road, Lake Charles, LA 70605. 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 will be offered a paper copy of this Notice during the admission or registration process. You may ask us to give you a copy of this Notice at any time, or you may contact our Privacy Officer at 337-475-4134. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You my obtain a copy of this Notice at our website, http://www.womenchildrens.com State Law Issues. Many states have requirements regarding the mandatory or voluntary reporting of health information for various purposes, such as maintaining records of births and deaths or engaging in activities relating to the improvement of health care or the reduction of health care costs. In addition, some states have enacted privacy laws or other laws respecting the confidentiality of medical information that have requirements different from, and in some cases more stringent than, those described herein. To the extent that an applicable state privacy law imposes requirements that are more restrictive than federal privacy law, the state law will preempt the federal law. Changes to This Notice We reserve the right to change this Notice at any time. We reserve the right to make the revised or changed Notice effective for medical and billing information we already have about you as well as any information we receive in the future. The effective date of the revised Notice will be on the first page, in the top right-hand corner. As of the effective date, distribution of the revised Notice that is in effect will be the same as above in the section describing your rights to receive a paper copy of the Notice. Complaints If you believe your privacy rights have been violated, you may file a complaint with the facility or with the Secretary of the Department of Health and Human Services. To file a complaint with the facility, contact [Title, address and phone number of the contact person or office responsible for handling complaints. This should be the same person or department listed on the first page as the contact for more information about this Notice.] If you prefer not to speak with a local person, you may file a complaint with the facility by calling this toll free anonymous hot line number, 1-800-345-8650. You will not be retaliated against or penalized for filing a complaint. The Secretary of the Department of Health and Human Services may be contacted at 200 Independence Ave. S.W. Washington, D.C. 20201 or by phone at 1-877-696-6775.