Notice of Privacy Practices

Our Pledge Regarding Medical Information:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive. This record is needed to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Good Samaritan, whether made by Good Samaritan 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. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Ensure that medical information identifying you is kept private
• Give you this notice of our legal duties and privacy practices with respect to medical information about you
• Follow the terms of the notice that are currently in effect
• Notify affected individuals if a breach of unsecured medical information occurs

How We May Use and Disclose Medical Information About You:

The following categories describe different ways that we use and disclose medical information. Each category of uses or disclosures we will explain and try to give some examples. Not every use or disclosure in every category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these 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, medical students, clinical students, or other hospital personnel who are involved in your care at Good Samaritan. For example, a doctor treating you for a broken leg may need to know if you have diabetes because it 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 may also share medical information about you in order to coordinate the things you need, such as prescriptions, lab work and X-rays. We may also disclose medical information about you to people outside the Hospital who may be involved in your medical care after you leave the Hospital, such as family members, clergy or others who 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 collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you receive at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval or determine whether your plan will cover the treatment.
• For Health Care Operations
  • ​We may use and disclose medical information about you for Good Samaritan operational reasons. These uses and disclosures are necessary to run the Hospital and ensure that all of our patients receive quality care. For example, we may use and disclose medical information to review our treatment and services, evaluate the performance of our staff in caring for you, or to accrediting agencies that evaluate our performance. We may also combine medical information about many Hospital patients to evaluate current services, decide what additional services the Hospital should offer, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, clinical students, and other Hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health care providers to compare how we are doing and areas for improvement in the care and services we offer. We may remove information that identifies you from this set of medical information so others can use it to study health care and health care delivery without learning who the specific patients are.
• Appointment Reminders
  • ​We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
• Treatment Alternatives
  • ​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 or services that may be of interest to you.
• Fundraising Activities
  • ​We may disclose information to the Good Samaritan Foundation so that the Foundation may contact you in raising money for the Hospital. We would only release contact information, such as your name, address and phone number and the dates you receive treatment or services at the Hospital; and your age, gender, and insurance status. If you do not want the hospital to contact you for fundraising efforts, you have the right to opt-out of receiving such communications by notifying our Privacy Officer in writing at the address at the end of this notice.
• Hospital Directory
  • ​We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This will allow your family, friends, and clergy to visit you in the hospital and generally know how you are doing. You will have the opportunity to have your information not listed in the directory.
• Individuals Involved in Your Care or Payment for Your Care
  • ​We may release medical information about you to friends and family members who are involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital. If possible, we will ask your permission prior to discussing your care with others. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
• 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 receive one medication to those who receive another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. Medical information about you may be disclosed to people preparing to conduct a research project; for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital. 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 hospital.
• As Required By Law
  • ​We will disclose 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 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.

Special Situations

• 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 or tissue donation and transplantation.
• Military and Veterans
  • ​If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
• Workers’ Compensation
  • ​We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health Risks
  • ​We may disclose 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 and deaths
    • To report reactions to medications or problems with products
    • 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 contracting or spreading a disease or condition
    • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
• Health Oversight 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 laws.
• Lawsuits and Disputes
  • ​If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
• Law Enforcement
  • ​We may release medical information if asked to do so by a law enforcement official for the purpose of:
    • Responding to a court order, subpoena, warrant, summons or similar process;
    • Identifying or locating a suspect, fugitive, material witness, or missing person;
    • Assisting the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
    • Reporting a death we believe may be the result of criminal conduct;
    • Reporting criminal conduct at the Hospital; and
    • In emergency 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.
• 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.
• National Security and Intelligence Activities
  • ​We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
• Protective Services for the President and Others
  • We may disclose medical information about you to authorized federal officials so they may provide protection to the President and other authorized persons of foreign heads of state 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 release medical information about you to the correctional institution or 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.
• Psychotherapy Notes
  • ​We must obtain an authorization for any use or disclosure of psychotherapy notes except for use by the originator of the notes for treatment; use or disclosure by us for our own training programs; use or disclosure by us to defend ourself in a legal action brought by you; disclosure to the Secretary of Health and Human Services to determine our compliance with the Privacy Regulation; disclosure required by law; disclosure permitted for health oversight activities; disclosure to a coroner, medical examiner or funeral director in carrying out their duties; or disclosure to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Your Rights Regarding Medical Information About You

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy
  • ​You have the right to inspect and obtain copies of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
  • To inspect and receive copies of medical information that may be used to make decisions about you, you must submit your request in writing to our Health Information Department. If you request a copy of the information, we may charge a fee for the cost of copying, mailing or other cost associated with your request.
  • We may deny your request to inspect and copy in certain very 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 Good Samaritan will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
• Right to Amend
  • ​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 Good Samaritan.
    To request an amendment, your request must be made in writing and submitted to our Health Information Department. In addition, you must provide a reason that supports your request.
    We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us 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 amendment;
    • Is not part of the medical information kept by or for Good Samaritan;
    • Is not part of the information which you would be permitted to inspect and receive copies of; or
    • Is accurate and complete.
• Right to an Accounting of Disclosures
  • You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you, excluding disclosures for purposes of treatment, payment or health care operations. This list will also exclude any disclosures you authorize in writing.
    To request an accounting of disclosures you must submit your request to our Health Information Department. Your request must state a time period. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any cost is incurred.
• 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. For example, you could ask that we not use or disclose information about any surgical procedures you may have had.

    We are not required to agree to your request except as set out below. 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 our Privacy Officer at the address listed at the end of this notice. 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) to whom you want the limits to apply, for example, disclosure to your spouse. We must agree to your request to restrict disclosure of medical information about you to a health plan if the disclosure is for the purpose of receiving payment or other health care operations, the disclosure is not required by law, and the medical information relates to services for which you have made payment in full.

• Right to Request Confidential Communications​
  • 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 our Privacy Officer at the address listed at the end of this notice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or 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 are still entitled to a paper copy of this notice.
    
    You may obtain a copy of this notice at our website, www.gshvin.org

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 notice will contain on the last page, in the bottom left-hand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Good Samaritan or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, contact the Privacy Officer at 812-885-3484. All complaints must be submitted in writing You will not be penalized for filing a complaint.

Other Uses of 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 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 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 that we provided to you.

We must obtain written permission for any use or disclosure of protected health information for marketing unless the communication is a face-to-face communication made by us to you or is a promotional gift of nominal value provided by us to you. If the marketing involves financial renumeration to us, the written permission signed by you must state that such renumeration is involved. We must obtain written permission from you for any disclosure of protected health information which is the sale of protected health information and such written permission must state that the disclosure will result in renumeration to us.

If you have any questions about this notice, please call:

Health Information Department
812-885-3371

Privacy Officer
812-885-3484

Address:
Good Samaritan
Health Information Department
520 South 7th Street
Vincennes, Indiana 47591