February 1, 2008 Privacy Notice THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY. We understand that medical information about you and your health is personal.  We are committed to protecting medical information about you.   This notice applies to all the medical records we maintain.  This notice will tell you about the ways in which we may use and disclose medical information about you.  It also describes our obligations and your rights regarding the use and disclosure of medical information. Protected Health Information (PHI) means individually identifiable health information, as defined by HIPAA:  (1) that is created or received by us and that relates to the past, present, or future physical or mental health or condition of an individual; (2) the provision of health care to an individual; (3) or the past, present, or future payment for the provision of health care to an individual; (4) and that can identify the individual or for which there is a reasonable basis to believe the information can be used to identify the individual.  PHI includes information of persons living or deceased. Uses and Disclosures of Your Protected Health Information The following categories describe different ways that we use and disclose PHI.  For each category of uses and disclosures we will explain what we mean and, where appropriate, provide examples for illustrative purposes.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted or required to use and disclosure PHI will fall within one of the categories. Your Authorization – Except as outlined below, we will not use or disclose your PHI unless you have signed a form authorizing the use or disclosure.  You have the right to revoke that authorization in writing except to the extent that we have taken action in reliance upon the authorization or that the authorization was obtained as a condition of obtaining coverage under your health insurance plan. Uses and Disclosures for Payment – We may make requests, uses and disclosures of your PHI as necessary for payment purposes.  For example, we may use information regarding your medical procedures and treatment to process and pay claims.  We may also disclose your PHI for payment purposes of the services or care you received by the Sleepy Eye Medical Center. Uses and Disclosures for Health Care Operations -  We may use and disclose your PHI as necessary for our health care operations.  Examples of health care operations include activities relating to compliance, auditing, rating, business management, quality improvement and assurance, and other functions related to your health insurance plan. Family and Friends Involved in Your Care – If you are available and do not object, we may disclose your PHI to your family, friends and others who are involved in your care or payment of a claim.  If you are unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may share limited PHI with such individuals.  For example, we may use our professional judgment to disclose PHI to your spouse concerning the processing of a claim.  If you direct us to do so, copies of your health care record may be released to these individuals for your continued health care including referrals to see a specialist.  This may include but not be limited to individuals you identify as an emergency name, nearest relative, next of kin, significant other, contact names, and/or financially responsible party.  Business Associates – At times we use outside persons or organizations to help us provide you with the medical care or services you need.  Your PHI may be shared with outside persons or organizations so that they can perform the job we’ve asked them to do and bill you or your third party payer for services rendered.   Examples of outside services, persons and organizations might include vendors that help us process your claims; or certain laboratory tests including pathology, radiology and anesthesia services.  So that your health information is protected, however, we require the business associate to appropriately safeguard your information.  Other business associates may include, but not be limited to, a financial auditing firm like Eide Bailly and Associates. Other Products and Services – We may contact you to provide information about other health-related products and services that may be of interest to you.  For example, we may use and disclose your PHI for the purpose of communicating to you new services or products that may add value to your health. 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 may disclose medical information to respond to a court order. Public Health Risks – We may disclose PHI 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 neglect or abuse; 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 may be at risk for contracting or spreading a disease or condition; To notify 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. Other Uses or Disclosures – We may make certain other uses and disclosures of your PHI without your authorization.  Examples are listed below. Continued Health Care:  Your PHI may be released to other health care providers either in the event of emergency care or you are being referred to see a specialist.  In these instances, healthcare information may be transmitted via fax machine. Directory:   We will use your name, location in the facility and general condition, for directory purposes.  This information may be provided to members of the clergy and to other people who ask for you by name.  You have the right to opt out of the Facility Directory.  To do so, please notify your nurse or the Privacy Officer, Cheryl Reiniger at 507-794-3591, ext. 342. Health Oversight Activities:  We may disclose PHI to a health oversight agency for activities authorized by law.  These oversight activities include for example, audits, investigations, inspections, and licensures.  These activities are necessary for the government to monitor the health care system, government programs and compliance with civil 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 a dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 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. Organ and Tissues Donations:  If you are an organ donor, we may disclose PHI 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. Marketing:  We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.  You have the right to opt out of Marketing promotions.  To so, please notify your nurse or the Privacy Officer, Cheryl Reiniger at 507-794-3591, ext. 342. Fund raising:  We may contact you as part of a fund-raising effort.  You have the right to opt out of  Fundraising efforts.  To so, please notify your nurse or the Privacy Officer, Cheryl Reiniger at 507-794-3591, ext. 342. Food and Drug Administration (FDA):  We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs or replacement. Workers’ Compensation:  We may disclose health information to the extent authorized by and to the extent necessary to comply with laws related to workers compensation or other similar programs established by law. Correctional Institution / Inmates:  Should you be an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI to the 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.  Minnesota Hospital Association:  We disclose health information to the Minnesota Health Information Network through the Minnesota Hospital Association. Law Enforcement:  We may release medical information if asked to do so by law enforcement official: 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 persons agreement; About a death we believe may be the result of criminal conduct; About criminal conduct at the Sleepy Eye Medical Center; 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. Coroner’s, Medical Examiners and Funeral Directors:  We may disclose PHI 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 PHI about patients of the medical center to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities:  We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Your Rights Regarding Medical Information About -  Although your health record is the physical property of the Sleepy Eye Medical Center Hospital & Clinics that compiled it, the information belongs to you.  You have the following rights regarding PHI 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 healthcare.  To inspect and copy medical information that may be used to make decisions about you, you must submit  your request in writing to the Sleepy Eye Medical Center’s Privacy Officer, Cheryl Reiniger.  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 in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed. Right to Amend – You have the right to request that PHI that we maintain about you be amended or corrected.  We are not obligated to make all requested amendments, but will give each request careful consideration.  To be considered, your amendment request must be in writing, must be signed by you or your representative, and must state the reasons for the amendment / correction request.  Amendment request forms are available from us at the address listed below. Right to an Accounting of Disclosures – You have the right to receive an accounting of certain disclosures made by us of your PHI.  Examples of disclosures that we are required to account for may include those to insurance companies, pursuant to valid legal process, or for law enforcement purposes.  To be considered, your accounting requests must be in writing and signed by you or your representative.  Accounting request forms are available from us at the address below.  The first accounting in any 12-month period is free; however, we may charge you a fee for each subsequent accounting you request within the same 12-month period. Restrictions on Use and Disclosure of Your PHI – You have the right to request restrictions on certain  uses and disclosures of your PHI for insurance payment or health care operations, disclosures made to persons involved in your care, and disclosures for disaster relief purposes.  For example, you may request that we not disclose your PHI to your spouse.  Your request must describe in detail the restriction you are requesting.  We are not required to agree to your request but will attempt to accommodate reasonable requests when appropriate.  We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate.  In the event of a termination by us, we will notify you of such termination.  You also have the right to terminate, in writing or verbally, any agreed-to restriction.  You may make a request for a restriction (or termination of an existing restriction) by contacting us at the telephone number or address below. Right to Request Confidential Communications – You have the right to request that communications regarding your PHI be made by alternative means or at alternative locations.  For example, you may request that messages not be left on voice mail or sent to a particular address.  We are required to accommodate reasonable requests if you inform us that disclosure of all or part of your information could place you in danger.  Requests for confidential communications must be in writing, signed by you or your representative and sent to us at the address below. 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.  To obtain a paper copy of this notice, please contact Sleepy Eye Medical Center’s Privacy Officer, Cheryl Reiniger at 507-794-3591, ext. 342. Changes to This Notice - We reserve the right to change this notice.  We reserve the right to make the revised or change notice effective for medical information we already have about you as well as any information we receive in the future.  The notice will contain on the first page, in the top right-hand corner, the effective date. Complaints - If you believe your privacy rights have been violated, you can file a complaint with us at the address below.  You may also file a complaint in writing with the Secretary of Health and Human Services in Washington, D.C. within 180 days of a violation of your rights.  There will be no retaliation for filing a complaint. If you have any questions about this notice, please contact:  Cheryl Reiniger, Director of Health Information Management, Sleepy Eye Medical Center, P. O. Box 323, Sleepy Eye, MN  56085; or by calling 507-794-3591, ext. 342 \\SEMC-SERVER1\Users\creiniger\HIPAA P&P inc forms\08-01-01 Privacy Notice.doc ASB-216   Rev:  02-01-08 Sleepy Eye Medical Center ~ Signature Page to the Privacy NoticeMRN                                              (Internal Use Only):   __________________________ Patient Name:  ____________________________________________Date Of Birth:  ___________________________ My signature below indicates that I have been provided with a copy of the facility’s Notice of Privacy Practices. Signature:  _________________________________________________Date:  _______________________________ If signed by a legal representative, relationship to patient: ____________________________________________________ Witnessed by:  _________________________________ *Please return this form to the Business Office.  Effective Date:  February 1, 2008.