Notice of Privacy Practices

Jordan Hospital
Compliance Department
275 Sandwich Street
Plymouth, MA 02360

Privacy Officer: (508) 830-2007

NOTICE OF PRIVACY PRACTICES

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.

1. JORDAN HOSPITAL, INC. HAS A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION.

   We are legally required to protect the privacy of information that is related to your health care that can be used to identify you. This information is called “protected health information” or PHI for short. PHI includes information that we have created or received about you and your health condition. We are required by law to provide you with this Privacy Notice that explains our privacy practices and how, when, and why we use and/or disclose your PHI.

   We are legally required to follow the privacy practices that are described in this notice. We reserve the right to change our privacy policies and the terms of this notice at any time. Before any important policy change goes into effect, we will change this notice. The new notice will be posted in all our registration areas for public viewing.

   You may request a copy of this notice at any time by contacting the Compliance Department at (508) 830-2007 or by viewing a copy of the notice on our web site.

2. THIS NOTICE APPLIES TO THE FOLLOWING ENTITIES AND INDIVIDUALS:
   1. Jordan Hospital, Inc. (referred to as the “Hospital”).
   2. The Hospital’s medical staff, health care professionals, staff and personnel.
   3. Any member of a volunteer group working at the Hospital.

3. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION.

   Personal information about you, your medical history and health care treatment may be recorded, either on paper or in computer files, as part of providing you with health care. This information is vital to the normal business operation of the Hospital, and therefore is necessary in order to provide you and others with the highest quality health care. Form #0031 (04/03)

   1. We may disclose your PHI for the following reasons:

   1. We may disclose your PHI for treatment. We may use medical information about you to provide you with medical treatment or services. For example: the Hospital may disclose medical information about you to physicians, nurses, technicians, medical students or hospital personnel who are involved with the administration of your care.

   2. We may disclose your PHI in order to bill and collect payment for the treatment and services provided to you. We may send a bill to you or to a third party payor for the rendering of services by the Hospital. The bill may contain information that identifies you, your diagnosis and procedures and supplies used. We may need to disclose this information to insurance companies to establish insurance eligibility benefits for you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims.

   3. We may disclose your PHI for health care operations. We may use your PHI to evaluate the performance of the health care services you received. We may also provide your PHI to our accountants, attorneys, consultants and others in order to make sure we comply with the laws that govern us.

   4. We may disclose your PHI in the event you require emergency treatment. If you need emergency treatment or if you are unable to communicate with us we may disclose your PHI if it is in your best interest.

   5. We may disclose your PHI when required by federal, state or local law, administrative or legal proceedings, health oversight activities, or by law enforcement. Some examples of these disclosures include PHI regarding victims of abuse, neglect or domestic violence and/or patients with gunshot and other wounds. In addition, the Hospital must disclose PHI when ordered to comply with a legal or administrative proceeding. We may also provide PHI in response to a subpoena, discovery request or other lawful process, but only if efforts have been made to contact you about the request.

   6. We may disclose your PHI for public health activities. We may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury or disability.

   7. We may disclose your PHI to Business Associates. Some services in our Hospital are provided through contracts with business associates. We may disclose PHI to our business associate so that they can perform the job we have requested and bill a third party for services rendered.

   8. We may disclose your PHI for purposes of organ donation. If you are an organ donor or have not indicated that you would prefer not to be one, 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 or tissue donation and transplantation.

   9. We may disclose your PHI for research purposes. In certain circumstances, we may provide PHI in order to conduct medical research. Your PHI will only be used or disclosed to researchers when the Hospital determines that the protocols have been established to ensure the privacy of your health information.

   10. We may disclose your PHI to avoid harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or person able to prevent or lessen such harm.

   11. We may disclose your PHI for specific government functions. We may disclose PHI of military personnel and veterans as required by military command authorities.

   12. We may disclose your PHI for worker’s compensation claims. We may provide PHI to comply with laws relating to worker’s compensation and other similar programs.

   13. We may disclose your PHI for appointment reminders and health-related benefits or services. We may use and disclose medical information to contact you as a reminder that you have an appointment for a treatment or medical care at the Hospital and to inform you of treatment alternatives or other health care services or benefits that we offer.

   14. We may disclose your PHI for philanthropy activities. We may use certain information (name, address, telephone number, dates of service) to contact you in our appeals to raise money for Jordan Hospital. The money raised will be used to expand and improve the services and programs we provide to the Jordan Hospital community. If you do not wish to be contacted for our fundraising efforts, please notify us by writing to the: Jordan Hospital Philanthropy Department, 275 Sandwich Street, Plymouth, Massachusetts 02360.

   15. We may disclose your PHI for law enforcement purposes. We may disclose PHI to assist officials in locating a suspect, fugitive, material witness or missing person. In addition, we may disclose PHI to officials regarding criminal conduct.

   16. We may disclose your PHI to coroners, medical 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 Hospital to funeral directors as necessary to carry out their duties.

2. You may object to the following uses and disclosures.

1. Facility Directory. We maintain a facility directory listing the name, room number, general condition, and if you wish religious affiliation. Unless you choose to have your information excluded from this directory, the information, excluding your religious affiliation, will be disclosed to anyone who requests it by asking for you by name. This information, including your religious affiliation, may also be provided to members of the clergy. You have the right during registration to have your information excluded from this directory and also to restrict what is provided and/or to whom.

2. Disclosures to family, friends or others. Health professionals, using their best judgment, may disclose to a family member, friend or other person that you indicate, unless you object in whole or in part, health information relevant to that person’s involvement in your care or payment related to your care.

3. All Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in this Section III, we will ask for your authorization before using or disclosing any of your PHI.

4. RIGHTS YOU HAVE REGARDING YOUR PHI.

   You have the following rights with respect to your PHI:

   1. Right to Inspect and Copy. You have the right to inspect and copy medical information that we retain on your behalf. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing and signed by you or your authorized representative. If you request a copy of the information, we may charge a reasonable fee in accordance with Massachusetts General Law for copying and the costs of postage and supplies associated with your request. You may obtain an access request form from the Health Information Services Department at (508) 830-2361.

      We may deny your request to inspect and copy in certain 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.

   2. Right to Request Amendment. 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 or for the Hospital. We may deny your request if you ask us to amend information that:

      1. Was not created by us
      2. Is not medical information that is kept by or for the Hospital
      3. Is not medical information you are permitted to inspect or copy
      4. Is accurate and complete.

      To request an amendment, your request must be made in writing and submitted to the Health Information Services Department, Jordan Hospital, 275 Sandwich Street, Plymouth, Massachusetts 02360. The amendment request must be in writing, signed by you or your authorized representative and must state the reasons for the amendment/correction request. You may obtain an amendment request form from the Health Information Services Department at 508-830-2361.

   3. Right to Request Restrictions. You have the right to request a restriction or limitation 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 the payment for your care, like a family member or friend. We are not required to agree to your request regarding restrictions on disclosure, however.

   To request a limit on the use and disclosure of your PHI, you must submit your request in writing to the Health Information Services Department, Jordan Hospital, 275 Sandwich Street, Plymouth, Massachusetts 02360. Your request should include the information you want to limit and to whom you want the limits to apply, for example, disclosures to your spouse.

   4. Accounting for Disclosure of Your PHI. You have the right to receive an accounting of certain disclosures made by us of your PHI on or after April 14, 2003, up to six (6) years prior to the date of the request. Requests must be made in writing and signed by you or your authorized representative. Accounting request forms are available from the Health Information Services Department at 508-830-2361. The first accounting in any 12-month period is free; you will be charged a fee of twenty-five dollars for each subsequent accounting you request within the same 12-month period.

   5. Right to Choose How We Send PHI. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Health Information Services Department, Jordan Hospital, 275 Sandwich Street, Plymouth, Massachusetts 02360. Your request must specify how or where you wish to be contacted.

5. COMPLAINTS. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Hotline at 800-330-6090. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. in writing within 180 days of a violation. There will be no retaliation for filing a complaint.

6. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE. You will be asked to sign an acknowledgement form that you received this Notice of Privacy Practices.

7. FOR FURTHER INFORMATION. If you have questions or need further assistance regarding this policy, you may contact the Privacy Officer, Jordan Hospital, 275 Sandwich Street, Plymouth, Massachusetts 02360 at 508-830-2007.

8. EFFECTIVE DATE. This Notice of Privacy Practices is effective April 14, 2003.