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:
- 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.
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.
We may use and disclose medical information to contact you as a reminder
that you have an appointment for treatment or medical care.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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
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
You may obtain a copy of this notice at our website,
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.
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) 885-3487. 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
Health Information Department
520 South 7th Street
Vincennes, Indiana 47591