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.

How we will use and disclose medical information about you.

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, medical students, or other hospital personnel involved in your care.

For example:  A doctor may need to tell a dietitian if you have diabetes in order to arrange the correct meals. Different departments of the hospital may share information in order to co-ordinate your care. We may share information with people outside the hospital such as family members, home health, or others we use to provide services that are part of your care.

For Payment:

We may use and disclose medical information about you so that 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 inform your health plan about treatment you are going to receive to obtain prior approval so your plan will cover treatment. We may need to share information with your insurance company about your surgery so your health plan will pay us or reimburse you.

For Health Care Operations:

We may use and disclose medical information about you for hospital operations. These are things that are necessary to run the hospital.

For example: We may use information to evaluate the performance of our staff in caring for you.

Other Health Care Operations:

We may combine information from many patients to plan necessary services.

We may use information for learning purposes.

We may use this information for appointment reminders.

We may use this information to tell you about treatment alternatives.

We may use your name and location in the hospital in the hospital directory.

We may release your medical information to your caregiver or someone who helps pay for your care.

We may release information to disaster relief personnel to locate family if necessary.

We may combine information from our hospital with that of other hospitals for quality review and for evaluating services offered or for research. We may remove information that indentifies you from this information. We will seek specific permission if researchers have access to information that would identify you.

We may use this information to contact you for hospital or our foundation fund raising. If you do not want to be contacted you must notify Adair County Hospital Foundation Director in writing.

We will disclose medical information about you when required by federal, state, or local law.

Other uses and disclosures hospitals are allowed to make without your explicit authorization: 

We may release medical information about you:

     *   If you are an organ donor we may release information to the organization handling  procurement or transplantation.

     *   If you are a member of the armed forces as required by military command authorities.

      *   For worker’s compensation or similar programs that provide benefits for work-related injury or illness.

     *   For public health activities These generally include:  prevention or control of disease, report of births and deaths, report of child abuse or neglect, report of reactions to medications, report of reactions to products, to notify people of recalls of products, to notify people exposed to disease they may contract or spread, to notify authorities of a victim of abuse, neglect, or domestic violence when authorized by the patient or required by law.

     *   To a health oversight agency as authorized by law.

     *   If you are involved in a lawsuit - in response to a court or administrative order, or in response to a subpoena, delivery request, or other lawful process by another party in the dispute. Efforts will be made to tell you about the request.

     *   To a coroner or medical examiner.

     *   To authorized federal officials in service to protect the President, other heads of state, or conduct special investigations.

     *   To the institution or official if you are an inmate of a correctional institution or under custody of law enforcement official

     *   To a law enforcement official in response to a court subpoena, warrant, summons or other lawful process, to identify a suspect, fugitive, witness, or missing person, about a victim, criminal conduct or a criminal death. In emergency circumstances concerning crime information.

  Other uses of your medical information:

  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 with written 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 in your written authorization.

We are unable to to take back any disclosures we have already made with your permission. We are required to retain our records of the care we provided to you.

Your Rights Concerning Privacy of Your Medical Information   

You have the right to inspect and copy your medical information including medical and billing records.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing.

If you request a copy we may charge a fee to cover the cost of copying, mailing, or other costs of other supplies associated with your request.

You have the right to request to amend medical information you feel is incorrect or incomplete. You may request an amendment for as long as the information is kept by us.

To request an amendment, your request including a reason to support your request, must be made in writing.

We may deny the request for an amendment:

If it is not in writing or does not include a reason to support the request.

If you ask us to amend information not created by us, unless that person that created the information is no longer available to make the amendment themselves.

If it is not part of the information kept by the hospital

If it is not part of the information you would be permitted to inspect

If the information is accurate and complete

You have the right to request a list of the disclosures we made of medical information about you.  Your request must state a time period no longer that six years and may not include dates before Feb. 26^th , 2003. The first list your request within a 12 month period will be free, we may charge the cost of providing additional lists. We will notify you of the costs involved and you may choose to withdraw, modify, or keep your original request at that time before any costs are incurred. Your request must be made in writing.

Your Rights Concerning Privacy of Your Medical Information   

You have the right to request restrictions on the medical information we use or disclose about you for treatment, payment, or health care operations and to someone who is involved in your care or payment for your care.

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 emergency treatment.

Your request must tell us what information you want to limit, whether you want to limit use or disclosure or both and who you want the limits to apply to. Your request must be made in writing.

You have the right to request confidential communication and that we communicate with you about medical matters in a certain way or at a certain location. You must make a request for confidential communication in writing stating how and where you wish to be contacted. We do not need a reason for your request. We will accommodate all reasonable requests if possible.

You have the right to a paper copy of this notice. You may ask us for a copy of this notice at any time. You may obtain a copy of this notice at the registration office.

All requests that are required in writing must be sent to:

                       Adair County Memorial Hospital

                             Medical Records

                             609 S.E. Kent

                             Greenfield, IA 50849  

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 the complaint must be submitted in writing to:

                    Privacy Officer

                    Adair County Memorial Hospital

                    609 S.E. Kent

                    Greenfield, IA 50849

You will not be penalized for filing a complaint.

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.

A copy of the current notice is posted in the hospital.

The notice contains the effective date on the first page.