This notice describes how medical information
about you may be used and disclosed and how you can get
access to this information. It has been developed to protect
patient's rights under the Health Insurance Portability &
Accountability Act (HIPAA). Please view it carefully.
This notice describes our hospital’s practice
and that of:
professional authorized to enter information into your
all departments and units
of the hospital
any member of a volunteer
group we allow to help you while you are in the hospital
all employees, staff and
other hospital personnel
Our Pledge Regarding Medical Information:
We understand that medical
information about you and health is personal. We are
committed to protecting medical information about you. We
create a record of the care and services you receive at the
hospital. We need this record to provide you with quality
care and comply with certain legal requirements. This notice
applies to all of the records of your care generated by the
hospital, whether made by the hospital personnel or your
personal doctor or other practitioners involved in your
care. 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
This notice will tell you about the ways in
which we may use and disclose medical information about you.
We also describe your rights and obligations we have
regarding the use and disclosure of medical information.
required by law to:
make sure the medical
information that identifies you is kept private;
give you this notice for
legal duties and privacy practices with respect to
medical information about you; and
follow the terms of the
notice that is currently in effect.
How We May
Use and Disclose Medical Information About You
The following categories
describe the different ways that we use and disclose medical
information. For each category of uses or disclosures we
will explain what we mean and try and 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, technicians,
healthcare students, clergy, or others who are involved
in your care. 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 that we can arrange for appropriate meals.
Different departments of the hospital also may share
medical information about you in order to coordinate the
different things you need, such as prescriptions, lab
work and x-rays. We also may disclose medical
information about you to people outside the hospital who
may be involved in your medical care after you leave the
hospital or others we or your physician uses to provide
services that are part of your care.
For Payment. We may use
and disclose medical information about you so that the
treatment and services you receive at the hospital may
be billed to and payment may be collected from you, an
insurance company or a third party. For example, we may
need to give your health plan information about the
therapy you received at the hospital so your health plan
will pay us or reimburse you for the therapy. 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 cover the treatment.
For Health Care
Operations. We may use and disclose medical information
about you for hospital operations. These uses and
disclosures are necessary to run the hospital and make
sure that 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 hospital patients to
decide what additional services the hospital should
offer, what services are not needed, and whether certain
treatments are effective. We may also disclose
information to doctors, nurses, technicians, healthcare
students, and other hospital personnel for review and
Appointment Reminder- We
may use and disclose medical information to contact you
as a reminder that you have an appointment for treatment
or medical care at the hospital.
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.
Health Related Benefits
and Services- We may use and disclose medical
information to tell you about health related benefits,
services, or medical education classes that may be of
interest to you.
Individuals Involved In
Your Care or Payment For Your Care- We may release
medical information about you to a caregiver who may be
a friend or family member. We may also give information
to someone who helps pay for your care.
Facility Directory. We
may use or disclose limited information about you in our
hospital directory while you are a patient at our
facility. This information may include your name, your
assigned patient unit and room number, your religious
affiliation, and a general description of your
condition. Your religious affiliation may be given to a
member of the clergy. The directory information, except
for religious affiliation, may be given to people who
ask for you by name.
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 tissue donation and transplantation.
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 received one
medication to those who received another, for the same
condition. All research projects, however, are subject
to a special approval process. We will 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
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 another person. Any
disclosure, however, would only be to someone able to
help prevent the threat.
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 patients of the medical
facility to funeral directors as necessary to carry out
Law Enforcement. We may
release medical information if asked to do so by a law
In response to a
court order, subpoena, warrant, summons, or similar
To identify or locate
a suspect, fugitive, material witness, or missing
About the victim of a
crime if, under limited circumstances, we are unable
to obtain the person’s agreement;
About a death we
believe may be the result of criminal conduct;
conduct at the medical center;
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.
As Required By Law. We
will disclose medical information about you when
required to do so by federal, state or local law.
Fundraising. We may contact you to raise money for the
hospital. We may disclose your name, address, phone
number, next of kin, and dates for which you received
hospital services to a foundation, which is working for
the hospital, so the foundation may contact you on
behalf of the hospital.
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.
the following rights regarding medical information 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 care.
To inspect and copy medical information that
may be used to make decisions about you, you may submit your
request in writing to Mends Medical Record Department or
We may deny your request to inspect and copy
in certain and very limited circumstances. If you are denied
access to medical information, you may request that the
denial be reviewed. The person conducting the review will
not be the person who denied the request.
Right to Amend.
If you feel that medical information we have about you is
incorrect or incomplete, you may ask to amend the
To request an amendment, your request must be
made in writing. Submit your request in writing to Mends
Medical Record Department or call
In addition, you must provide a reason that supports your
We may deny your request for an amendment if
it is not in writing or does not include the reasons to
support the request. In addition, we may deny your request
if you ask 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
is not part of the
medical information kept by or for the hospital;
is not part of the
information which you would be permitted to inspect
and copy; or
is accurate and
Right To An Accounting Of Disclosure.
You have the right to request an accounting of disclosure.
This is a list of the disclosures we made of medical
information about you.
To request this list or accounting of
disclosures, you may submit your request in writing to Mends
Medical Record Department or call
Your request must state a time period which may not be
longer than six years.
Right to Request Restrictions.
You have the right to request a restriction on or limitation
on the medical information that we use or disclose about you
for treatment, payment or healthcare 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 the payment of 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.
We Are Not Required to Agree to Your Request.
If we do agree, we will comply with your request unless the
information is needed to provide you emergency treatment.
To request restrictions, you must make your
request in writing to Mends Medical Record Department or
We will not ask you for the reason for your request. We will
accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
Changes to This Notice.
We reserve the right to change this notice. We reserve the
right to make the revised or changed 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 the hospital. The effective date of
the notice will be indicated on the first page of the
notice. In addition, each time you register or are
readmitted to the hospital for treatment or health care
services as inpatient or outpatient, we will offer you a
copy of the current notice in effect.
If you believe your privacy rights have been violated, you
may file a complaint with the hospital or with the Secretary
of the Department of Health and Human Services. To file a
complaint with the hospital, contact Mends Privacy Officer
All complaints must be submitted in writing. You will not be
penalized for filing a complaint.
Other Uses of Medical
Other uses and disclosure 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 that 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 we provide to you.
If you have any questions about this notice,
please contact us at