Effective Date: April 14, 2003

Approved By: John Rau, President & CEO

Each time you visit Stevens Community Medical Center (SCMC), a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment, and billing related information. This notice applies to all the records of your care generated by SCMC whether made by SCMC's facility personnel, agents of SCMC, or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic other than SCMC.

We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

How we may use and disclose medical information about you.

The following categories describe examples of the way we use and disclose medical information:

For treatment: We may use medical information about you to provide you treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other SCMC personnel who are involved in taking care of you at SCMC. For example: a doctor treating you for an injury may need to know if you have diabetes, because diabetes may slow the healing process, or if your Doctor orders Physical Therapy, the nursing staff will need to discuss your care and treatment with the Physical Therapist. Different departments of SCMC also may share medical information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals, and x-rays.

We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from SCMC.

For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.

For Health Care Operations: Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients/clients we serve. For example, we may combine medical information about many patients/clients to evaluate the need for new services, treatment, or equipment. We may disclose information to doctors, nurses, and other students for educational purposes.

We may also use and disclose medical information:

• To business associates we have contracted with to perform the agreed upon service and billing for it;
• To remind you that you have an appointment for medical care
• To assess your satisfaction with our services;
• To tell you about possible treatment alternatives;
• To tell you about health-related benefits or services;
• For Population based activities relating to improving health or reducing health care costs;
• For conducting training programs and reviewing competence of health care professionals.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples may include physician services in the emergency department and radiology, certain outside laboratories, or a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill you or your third party for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Patient Directory: We may include certain limited information about you in the directory while you are here. The information may include your name, location in the facility, your general condition (e.g. fair, stable, etc,) and your religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the directory, please request the form "REQUEST TO RESTRICT USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION"from the admission staff, admitting nurse/clerk or Facility Privacy Officer.

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 or who helps pay for your care. 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.

Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.

Future Communications: We may communicate to you via newsletters, mail outs, or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our facility is participating in.

Affiliated Covered Entity: Protected health information will be made available to your physician or caregiver as necessary to carry out treatment, payment, and health care operations.

As Required by Law:

Federal Law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the 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 including billing records. You must submit your request in writing to the address listed on the front of the Privacy Statement. If you request a copy of the information, SCMC may charge a fee for copying and assembling cost associated with your request. 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 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.
• 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 our facility. A request for an amendment of records must be made in writing to the address listed on the front of the Privacy Statement. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial. SCMC may deny the request if the written request does not include a reason for the amendment. The request also may be denied if your health information records were not created by SCMC, if the records you are requesting are not part of SCMC's records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of SCMC, the records containing your health information are accurate and complete.
• An Accounting of Disclosures: You have the right to request an accounting of disclosures of your health information that were made by SCMC, if any, without your written authorization to third parties for purposes other than for treatment, payment or health care operations and certain other limited purposes. These disclosures are typically those required by law for purposes such as disease management, protection of vulnerable adults and children, and birth and death reporting. The request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. SCMC would provide the first accounting you request within any 12-month period without charge. We may charge you for providing additional accounting lists. You will be notified of the costs involved and you may choose to modify or withdraw your request at that time before any costs are incurred.
• Request Restrictions: You have the right to request a restriction or limitations on the medical information we use or disclose about you for treatment, payment, or health care 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 payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. To request restrictions, you must make your request in writing. (A "Request to Restrict Use and Disclosure of Protected Health Information" form is available at SCMC.)

• Request Confidential Communications: You have the right to request that we communicate about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes. To confidential communications, you must make your request in writing. (A "Request to Restrict Use and Disclosure of Protected Health Information" form is available at SCMC.)

• 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 requested to receive this notice electronically, you are still entit led to a paper copy of this notice.

To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted at SCMC and on our website and it will include the effective date. In addition, each time you register at SCMC for treatment or health care services, a copy of the current notice will be available.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with SCMC or the Secretary of the Department of Health and Human Services. To file a complaint with SCMC contact the HIPAA Compliance Officer at the above address. All complaints must be submitted in writing.

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 written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided you.

Revised April 17, 2003