NOTICE OF PRIVACY PRACTICES
LAKE VIEW MEMORIAL HOSPITAL

Effective Date: April 14, 2003

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.

If you have any questions about this notice, please contact the Facility Privacy Official by dialing 218-834-7303.

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, diagnoses, treatments, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by Lake View Memorial Hospital and Home (the hospital), whether made by hospital personnel, agents of the hospital, or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of our medical information created in the doctor’s office or clinic.

Our Responsibilities

We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

USES AND DISCLOSURES

How we may use and disclose Medical information about you.

The following categories describe examples of the way we use and disclose medical information:

For treatment: We may use medical information about you to provide you treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at the hospital. For example: a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments of the hospital also may share medical information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals, and x-rays. We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from the hospital.

For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.

For Health Care Operations: Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. For example, we may combine medical information about many patients to evaluate the need for new services or treatments. We may disclose information to doctors, nurses, and students for educational purposes. And we may combine medical information we have with that of other hospitals to see where we can make improvements. We may remove information that identifies you from this set of medical information to protect your privacy.

We may also use and disclose medical information:

• To business associates we have contracted with to perform an agreed upon service;
• To remind you that you have an appointment for medical care;
• To assess your satisfaction with our services:
• To tell you about possible treatment alternatives;
• To tell you about health-related benefits or services;
• For health department or regulatory agency activities relating to improving health;
• For conducting training programs or reviewing competence of health care professionals.

Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and certain laboratory test. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital. The information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the facility directory please ask the admission staff or Facility Privacy Official for the appropriate form to complete.

Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. 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.

Future Communications: We may communicate to you via newsletters, mailings or other means regarding treatment options, health related information, disease-management programs, wellness programs, fundraising events, or other community based initiatives or activities our facility is participating in.

Organized Health Care Arrangement: This facility and its medical staff members are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment and health care operations.

As Required by Law, we may also use and disclose health information for the following types of entities, including but not limited to:

• Food and Drug Administration
• Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
• Correctional Institutions
• Workers Compensation Agents
• Organ and Tissue Donation Organizations
• Military Command Authorities
• Health Oversight Agencies, such as Medicare or Medical Assistance
• Funeral Directors or Medical Examiners
• National Security and Intelligence Agencies
• •Protective Services for the President and Others

Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a court order or search warrant.

YOUR HEALTH INFORMATION RIGHTS

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the Right to:

Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. 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. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

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 the hospital. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures: You have the right to request an accounting of disclosures that occurred after April 13, 2003. This is a list of the disclosures we make of medical information about you. The list will not include disclosures made for treatment, payment or healthcare operations.

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 a surgery you had. All such requests must be in writing.

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 you emergency treatment.

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. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes.

To exercise any of your rights, please obtain the required forms from the Privacy Official and submit your request in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the hospital and include 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 the hospital by calling 218-834-7303 between 7:00 a.m. and 3:30 p.m. on weekdays and asking for the Facility Privacy Official, or with the Secretary of the Department of Health and Human Services. You may be asked to submit your complaint 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. We are unable to take back any disclosures we have already made with your permission. We are required to retain our records of the care that we provide to you.

PRIVACY OFFICIAL

Lake View Memorial Hospital and Home’s Privacy Official may be reached by calling 218-834-7303.