Notice of Privacy Practices

BOX BUTTE GENERAL HOSPITAL AND AFFILIATED CLINICS

BOX BUTTE GENERAL HOSPITAL: This Notice describes the privacy practices of Box Butte General Hospital (the "Hospital") and all of its programs and departments, including its rural health clinics.

PLEASE REVIEW CAREFULLY

UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION:

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment
• means of communication among the many health professionals who contribute to your care
• legal document describing the care you received
• means by which you or a third-party payer can verify that services billed were actually provided
• a tool in educating health professionals
• a source of information for public health officials charged with improving the health of the nation
• a source of data for facility planning and marketing
• a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
• Understanding what is in your record and how your health information is used helps you to:
• ensure its accuracy
• better understand who, what, when, where and why others may access your health information
• make more informed decisions when authorizing disclosure to others

YOUR HEALTH INFORMATION RIGHTS:

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

• request a restriction on certain uses and disclosures of your information
• obtain a paper copy of the notice of privacy practices upon request
• inspect and copy your health record
• amend your health record following policy and procedure of health care provider
• obtain an accounting of disclosures of your health information
• request communications of your health information by alternative means or at alternative locations
• revoke your authorization to use or disclose health information except to the extent that action has already been taken

OUR RESPONSIBILITIES:

This organization is required to:

• maintain the privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice
• notify you if we are unable to agree to a requested restriction
• accommodate reasonable requests you may have to communicate health information by alternative locations

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide notice of such changes. We will not use or disclose your health information without your authorization, except as described in this notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM:

If you have questions and would like additional information, you may contact our Director of Health Information Management at (308) 761.3397.

• If you believe your privacy rights have been violated, you can:
• file a complaint with our Director of Health Information Management , or
• file a complaint with the Office of Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth St., S.W., Atlanta, GA 30303-8909.

There will be no retaliation for filing a complaint.

DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS:

We will use your health information for treatment. For example: Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you.

Consent for treatment includes use by:

• Utilization Review Nurse - who will call your insurance carrier for certification of hospitalization which includes observation and/or inpatient stays.
• Billing Audits: Internal and external audit processing for billing accuracy.
• Other Health Care Providers: Information may be released to other health care providers who participated in your care (i.e. Radiologist).

We will use your health information for payment.

• A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
• Your account information may be released to our Business Associates to assist in activities related to the collection of patient balances and to answer your questions regarding your account. The information that would be shared include your name, address, and telephone number, social security number, place of employment, next of kin, and detailed account information. Information relating to charity relief or bankruptcy would be shared if applicable.
• Patient Financial Services may check with Medicare Part D Prescription Drug Plans to see if you are eligible for the Medicare Part D benefit. Even though Box Butte General Hospital does not have a retail pharmacy, eligibility will need to be verified to determine patient financial responsibility.

We will use your health information for regular health operations.

• Members of the medical staff, the risk or quality improvement manager or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

MEDICAL STAFF:

This Notice also describes the privacy practices of an "organized health care arrangement" or "OHCA" between the Hospital and eligible providers on its Medical Staff. Because the Hospital is a clinically-integrated care setting, our patients receive care from Hospital staff and from independent practitioners on the Medical Staff. The Hospital and its Medical Staff must be able to share your medical information freely for treatment, payment and health care operations as described in this Notice. Because of this, the Hospital and all eligible providers on the Hospital's Medical Staff have entered into the OHCA under which the Hospital and the eligible providers will:

• use this Notice as a joint notice of privacy practices for all inpatient and outpatient visits and follow all information practices described in this notice,
• obtain a single signed acknowledgment of receipt, and
• share medical information from inpatient and outpatient hospital visits with eligible providers so that they can help the Hospital with its health care operations.

The OHCA does not cover the information practices of practitioners in their private offices or at other practice locations.

BUSINESS ASSOCIATES: There are some services provided in our organization through contracts with business associates. Examples include physician's services in Radiology, certain laboratory tests. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we've asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

DIRECTORY: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

NOTIFICATION: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

COMMUNICATION WITH FAMILY: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

RESEARCH: Only if you have agreed to a specific type of research project and signed authorization requesting medical information to be sent then health information would be released.

FUNERAL DIRECTOR: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

ORGAN PROCUREMENT ORGANIZATIONS: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

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.

FUND RAISING: We may contact you as part of a fund-raising effort.

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.

NATIONAL ELECTRONIC INJURY SURVEILLANCE SYSTEM: We may disclose health information to NEISS (Consumer Product Safety Commission) in the event of any type of injury and you are treated in the Emergency Department at Box Butte General Hospital.

WORKERS COMPENSATION: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Privacy Practices DO NOT protect you from these disclosures.

PUBLIC HEALTH: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

CORRECTIONAL INSTITUTIONS: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and safety of other individuals.

COURT OR ADMINISTRATIVE ORDER: We may disclose health information in response to a court or administrative order. To be valid, a subpoena must be accompanied by SATISFACTORY ASSURANCES.

TELEHEALTH: Telehealth may be utilized in the Emergency Department for the purpose of consultation between the attending medical provider(s) at Box Butte General Hospital and consulting provider(s) at another medical facility.

NEWS MEDIA: Patients must authorize release of their names to the news media. News Media includes, but not limited to Radio, Newspaper and Internet Websites.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical
standards that are potentially endangering one or more patients, workers or public.