WHO WILL FOLLOW THIS NOTICE
This notice describes the privacy practices of Phelps Memorial Health Center, hereafter referred to as PMHC, including those of:

• Any health care professional authorized to enter information into your hospital chart
• All areas of PMHC, including North Park Therapy Center, Home Health Care, Home Medical Equipment, and PMHC PACE
• Any volunteer we allow to help you while you are receiving care
• All PMHC employees, staff and other hospital personnel, including consulting professionals
• The above may share medical information with each other for treatment, payment, or hospital operations as described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal, and we will try to protect that information. We create a record of the care and services you receive. This record helps us to provide quality care and meets legal requirements. This notice covers all records of your care, generated by any agency of the hospital, whether made by hospital personnel 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.

This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and our responsibilities regarding the use and disclosure of your medical information.
We are required by law to:

• Make sure that medical information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices; and 
• Follow the terms of the privacy notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following lists some examples of how we may use and disclose medical information. However, not every use and disclosure is listed.

For Treatment. We may provide medical information about you to doctors, nurses, technicians, residents, medical students or other personnel who take care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes since diabetes may slow healing. In addition, the doctor may also need to tell a dietician that you have diabetes so we can arrange for the right meals. We may share medical information about you with people and companies outside PMHC involved in your ongoing medical care, such as family members, clergy or others we use to provide services that are part of your care.

For Payment. We may use medical information about you so that the treatment and services you receive can be billed and payment collected from you, an insurance company or a third party. For example, we may need to give your insurance company information about your surgery so the insurance company will pay us for the surgery. We may tell your health plan about a treatment you are going to receive to obtain approval or to determine whether your health plan will cover the treatment. We may also provide medical information about you to companies outside PMHC who need this information to bill for services they provided.

For Health Care Operations. We may use medical information about your health care operations that help us provide quality care. For example, we may use medical information to review our treatment, services and the performance of our staff in caring for you. We may also combine medical information about patients to decide what additional services PMHC should offer, what services are not needed, and whether certain new treatments are effective. We may provide information to doctors, nurses, technicians, medical students and other hospital personnel for review and learning purposes. We may provide medical information about you to companies outside of PMHC for health care operations as long as both companies have treated you. We may also combine medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in care and services. We will remove information that identifies you from this set of medical information so that others may use it to study health care and health care delivery without being able to identify you.

Business Associates. We may provide medical information to other persons or organizations, known as business associates, who provide services for us under contract. We require our business associates to protect the medical information we provide to them.

Appointment Reminders. We may use and provide medical information to contact you as a reminder that you have an appointment for treatment or medical care with us.

Treatment Alternatives. We may use and provide medical information to tell you about possible treatment options or other items of interest.

Health-Related Benefits and Services. We may use and provide medical information to tell you about health-related benefits or services of interest.

Fundraising Activities. We may provide medical information about you to our hospital-related foundation so the foundation may contact you in raising money for the hospital. We will only release information, such as your name, address and phone number and the dates you received treatment or services. If you do not want to be contacted for fundraising efforts, you must contact the Phelps Memorial Hospital Foundation in writing.

Hospital Directory. We may include limited information such as your name and location in the hospital directory while you are a patient. The directory information may also be given to people who contact the hospital and ask for you by name. This is so your family, friends and clergy may visit you in the hospital. You do have the option to exclude your name from the hospital directory.
 
Individuals Involved in Your Care and Payment for Your Care. We may provide medical information about you to a friend, family member or any other person you say is involved in your medical care or in the payment for your care. We will only provide this information if you tell us to or if we think that normally it is in your best interest to allow a person to act on your behalf. For example, you may identify a friend or family member to pick up medical supplies for you. We will only provide the medical information needed to allow the person to complete that task. In addition, we may provide medical information about you to someone helping in a disaster relief effort so that your family can be notified about your condition, status and location.

Research. We may use medical information about you for research purposes. For example, a research project may involve comparing the health of all patients who received one medicine to those who took another for the same condition. All research projects are subject to a specific approval process. This process reviews a proposed research project and its use of medical information, comparing the research needs with patients’ need for privacy of their medical information. We may provide medical information about you to people preparing a research project. For example, to help them look for patients with specific medical needs, so long as the medical information they receive does not leave the hospital. Normally, we will ask you to agree if the researcher will have access to your name, address or other information that shows your identity.

As Required by Law. We will provide medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and provide medical information about you when needed to prevent a serious threat to your health and safety or the health and safety of other people. This information will only be provided to someone able to help prevent the threat.
SPECIAL SITUATIONS
Organ and Tissue Donation. If you are an organ donor, we may provide medical information to organizations that handle organs for organ, eye or tissue transplantation or to an organ donation bank.

Workers’ Compensation. We may provide medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.

Public Health Activities. We may provide 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 or deaths;
    * To report child abuse or neglect;
    * 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 getting or spreading a disease or condition;
    * To notify the government if we suspect a patient has been the victim of abuse,
      neglect or domestic violence. We will make this disclosure if you agree or when
      required or authorized by law.

Health Oversight Activities. We may provide medical information to a health oversight agency for activities allowed by law. Oversight activities that allow the government to monitor the health care system, government programs and compliance with civil rights laws include audits, investigation and inspections.

Lawsuits and Disputes. We may provide medical information about you in response to a court or administrative order. We may also provide medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in a dispute.

Law Enforcement. We may provide medical information if asked to do so by a law enforcement official, examples being;
    Response to a court order, subpoena, warrant, summons or similar process
    Identity or locate a suspect, fugitive, material witness, or missing person;
    Inquiries as to the victim of a crime, if, under certain limited circumstances, we are unable to obtain the person’s agreement;
    Inquiries as to a death we believe may be the result of criminal conduct;
    Inquiries as to criminal conduct at the hospital; and 
    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 provide medical information to a coroner or medical examiner. For example, to identify a person who has died or to determine the cause of death. We may also provide medical information about patients to funeral directors that need to carry out their duties.

Disclosures Required by Law. We may use or disclose your health information as required by law provided such use or disclosure complies with and is limited to the relevant requirements of such law.

Protective Services for the President and Others. We may provide medical information about you to federal officials so they may provide protection to the President, other authorized persons or 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 provide medical information about you to the correctional institution or under the custody of a 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
Other uses of medical information not covered by this notice or the laws that apply to us will be made only if you agree in writing. If you give us the right to use medical information about you, you may change your mind, in writing, at any time. If you change your mind, we will no longer use the medial information for the reasons covered by your written request. You understand that we cannot take back any information that we have already released with your written agreement and that we are required to retain record of the care we provide.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical information we have about you:

Right to Look at and Copy. You have the right to look at and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. This does not include psychotherapy records.
You must send your request to look at and copy medical information that may be used to make a decision about you in writing to the Medical Record personnel. If you ask for a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies needed to meet your request.
We may deny your request to look at and copy medical information. If we do not let you look at your medical information, you may request that the denial be reviewed. A 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 follow the outcome of the review.

Right to Change. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to change the information. You have the right to ask for a change as long as the information is kept by PMHC.
Your request for a change must be in writing and sent to the Medical Records Department. In addition, you must provide a reason that supports your request for a change.
We may deny your request for a change if it is not in writing or does not include a reason to support the request. In addition, we may deny your request to change information, if the information is:
    Not created by us, unless the person or company that created the information is
    no longer available to make the change;
    Not part of the medical information kept by or for PMHC
    Not part of the information you would be allowed to look at and copy under the law; or Correct and complete.

Right to an Accounting of Disclosures. You have the right to ask for an accounting of disclosures, which is a list of medical information given out about you. To ask for an accounting of disclosures, you must send a request in writing to the Medical Records Department. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should say in what form you want the list (for example, on paper or electronically). The first list of disclosures you ask for within a 12-month period will be free. We may charge for the costs of providing additional lists. We will notify you of the cost and you may choose to remove or change your request before any costs are incurred.

Right to Request Restrictions. You have the right to limit the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to ask for a limit on the medical information we provide about you to someone who is involved in your care or the payment for care, like a family member or friend. We do not have to agree with your request. If we do agree to a limitation you ask for, we will follow your request unless the information is needed to provide emergency treatment.
You must request a limitation in writing to the Privacy Officer. In your request you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) who you want the limits to apply to.

Right to Ask for Private Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. To ask for private communication, you must make your request in writing. We will not ask you the reason for your request and we will agree with all reasonable requests. Your request must say how and 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 may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you may ask for a paper copy. You may get a copy of this notice at our website, www.phelpsmemorial.com. To obtain a paper copy of this notice, contact the Privacy Officer.

CHANGES TO THIS NOTICE
We reserve the right to or may be required by law to change our privacy practices, which may result in changes to this notice. We further keep the right to make the most current privacy practices notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in each Phelps Memorial Health Center location and on our website. This notice will include the version number and effective date. In addition, each time you come to the hospital or are otherwise treated by Phelps Memorial Health Center, we will offer you a copy of the current notice in effect. 

COMPLAINTS
If you think your privacy rights have been violated, you may complain to the Phelps Memorial Health Center Privacy Officer or the Secretary of the Department of Health and Human Services. To file a complaint with Phelps Memorial Health Center, contact the Privacy Officer. All complaints must be submitted in writing. You will not be penalized or otherwise retaliated against for filing a complaint.

ORGANIZED HEALTH CARE ARRANGEMENT (OHCA) Phelps Memorial Health Center will participate in an Organized Health Care Arrangement (OHCA). This means that all participants will follow the same “Notice of Privacy Practice” that you are receiving.

The following are participants in the OHCA: all physicians who are on staff at PMHC, all consulting physicians who see patients within PMHC, Certified Nurse Anesthetists practicing at PMHC. If you receive services from any of these individuals outside of PMHC (such as the physician’s own office), that office is bound by their own notice of privacy.

Phelps Memorial Health Center
1215 Tibbals Street
Holdrege, Nebraska 68949-1255
Phone: 308-995-2211 Fax: 308-995-3333

Phelps Memorial Health Center   •   1215 Tibbals Street   •   Holdrege, Nebraska   •   308-995-2211

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