WILLIAMSON MEMORIAL HOSPITAL
Effective Date: 4/14/03
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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO
US.
If you have any questions about this notice please contact our Privacy Officer at: 304-235-2500
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your medical information. We are
also required to give you this notice about our privacy practices, our legal duties, and your rights concerning
your medical information. We must follow the privacy practices that are described in this notice while it is in
effect. This notice takes effect 04/14/2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such
changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the
new terms of our notice effective for all medical information that we maintain, including medical information we
created or received before we made the changes. Before we make a significant change in our privacy practices, we
will change this notice and make the new notice available upon request.
You may request a copy of our notice at any time. For more information about our privacy practices, or for
additional copies of this notice, please contact us using the information listed at the end of this notice.
Who Will Follow This Notice
This notice describes our hospital's practices and those participants listed below in our organized health care
arrangement. As such, we may share your medical information and the medical information of others we service with
each other as needed for treatment, payment or health care operations relating to our organized health care
arrangement.
This notice does not imply any joint venture or any other special association or legal relationship
between the hospital and its medical staff. This notice is an administrative tool permitted by federal law
allowing the hospital and medical staff to tell you about common privacy practices.
Along with the hospital, the following participate in our organized health care arrangement:
- Members of our medical staff and their employees or workforce who provide services or support to the
physician at the hospital.
- Our employed physicians and their office staff.
Uses and Disclosures of Medical Information
We use and disclose medical information about you for treatment, payment, and health care operations. For
example:
Treatment: We may use or disclose your medical information to a physician or other health care
provider in order to provide treatment to you.
Payment: We may use and disclose your medical information to obtain payment for services we
provide to you. We may disclose your medical information to another health care provider or entity subject to the
federal and state Privacy Rules so they can obtain payment.
Health Care Operations: We may use and disclose your medical information in connection with
our health care operations. These uses are necessary to make sure that all our patients receive quality care.
Some examples are:
- Review of our treatment or services to evaluate the performance of our staff providing your
care;
- sending you a satisfaction survey;
- review of information about many of our patients to determine if additional services should be added or
perhaps are no longer needed;
- information may be given to our doctors, nurses, medical and health care students, and other personnel to
be used for education and learning purposes;
- we may remove information that identifies you from the medical information so others may use it for
studies in health care delivery without learning who the patients are; and
- we may disclose your medical information to another provider who has a relationship with you and is
subject to the same Privacy rules, for their health care operation purposes.
On Your Authorization: You may give us written authorization to use your medical information
or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any
time. Your revocation will not affect any use or disclosures permitted by your authorization while it was
in effect. Unless you give us a written authorization, we cannot use or disclose your medical information for any
reason except those described in this notice.
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 at the hospital.
To Your Family and Friends: Unless you object, we may disclose your medical information to a
family member, friend or other person to the extent necessary to help with your health care or with payment for
your health care.
If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical
information based on our professional judgment of whether the disclosure would be in your best interest.
We will also use our professional judgment and our experience with common practice to allow a person to pick up
filled prescriptions, medical supplies, x-rays or other similar forms of medical information.
Hospital Directory: We may use your name, your location in our facility, your general medical
condition, and your religious affiliation in our facility directories. We will disclose this information to
members of the clergy and, except for religious affiliation, to other persons who ask for you by name. We
will provide you with an opportunity to restrict or prohibit some or all disclosures for facility directories
unless emergency circumstances prevent your opportunity to object. In addition, we may disclose medical
information about you to an organization assisting in a disaster relief effort so your family can be notified
about your condition and location.
By Law or Special
Circumstances: We may use or
disclose your medical information as authorized by law for the following
purposes deemed to be in the public interest or benefit:
- as required by law;
- for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA
oversight, and to employers regarding work-related illness or injury;
- to report adult abuse, neglect, or domestic violence;
- to health oversight agencies;
- In response to court and administrative orders and other lawful processes;
- to law enforcement officials after receiving subpoenas and other lawful processes, concerning crime
victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of
identifying or locating a suspect or other person;
- to coroners, medical examiners, and funeral directors;
- to organ procurement organizations;
- to avert a serious threat to health or safety;
- in connection with certain research activities;
- to the military and to federal officials for lawful intelligence, counterintelligence, and national
security activities;
- to correctional institutions regarding inmates;
- and as authorized by state worker's compensation laws.
Health Related Benefits and Services: We may use your medical information to contact you with
information about health-related benefits and services or about treatment alternatives that may be of interest to
you. We may disclose your medical information to a business associate to assist us in these activities.
We may use or disclose your medical information to encourage you to purchase or use a product or service by
face-to-face communication or to provide you with promotional gifts.
Use and Disclosure of Certain Types of Medical Information
For certain types of medical information we may be required to protect your privacy in ways more strict than we
have discussed in this notice. We must abide by the following rules for our use or disclosure of certain types of
your medical information or purposes of use or disclosure of your medical information:
HIV Information. We may not disclose HIV information unless required by law, pursuant to an authorization or
the disclosure is to you or your personal representative; to health care personnel providing care to you, when
knowledge of HIV test results is necessary or useful to provide appropriate care or treatment; to victims of
sexual abuse, sexual assault, incest or sexual molestation (but only at the request of the victim); to persons
employed by (or agents of) health care providers (including our own facility) who provides care to you, handles or
processes bodily fluids or tissues and has a need to know such information; to persons employed by (or agents of)
a funeral establishment who handles or processes bodily fluids or tissues and has a need to know such information;
to organ donation entities for purposes of procuring, processing or transplanting; to relevant persons involved in
blood transfusions and blood processing; to pursuant to appropriate court orders; or, to your spouse, sex partners
or contacts who have shared needles with you who may be at risk of acquiring HIV infection.
Information Received by Social Workers. Social workers may not release to any other person any medical
information they receive from you in their capacity as a social worker unless you (or your personal
representative) has authorized the disclosure, except under the following circumstances: when a communication
reveals the contemplation of a crime or harmful act; when you waive the privilege by initiation of formal charges
against the social worker or the facility as the employer of the social worker; if you are a minor and you have
revealed to the social worker that you have been the victim or subject of a crime and the social worker may be
required to testify in an examination, trial or other legal proceeding in which the commission of crime is the
subject of the inquiry; or as may be required by law.
Information Received From Licensed Professional Counselors. Licensed professional counselors may not release
to any other person any medical information they receive from you in their capacity as a licensed professional
counselor counseling you unless you (or your personal representative) has authorized the disclosure, except under
the following circumstances: when a communication reveals the contemplation of a crime or harmful act; when you
waive the privilege by bringing charges against the licensed professional counselor or the facility as the
employer of the licensed professional counselor; or as may be required by law.
Alcohol and Drug Abuse Information. We may not disclose your medical information that contains alcohol and
drug abuse information except to you, your personal representative or pursuant to an authorization or as may
otherwise be allowed by law.
Your Rights Regarding Medical Information About You
Right to Inspect and Copy: You have the right to look at or get copies of your medical
information, with limited exceptions. You must make a request in writing to obtain access to your medical
information. You may obtain a form to request access by using the contact information listed at the end of this
notice. You may also request access by sending us a letter to the address at the end of this notice. If you
request copies, we will charge you a fee for copying and postage if you want the copies mailed to you. Contact us
using the information listed at the end of this notice for a full explanation of our fee structure.
We may deny your request to inspect and copy in very limited circumstances as allowed by law. If you are denied
access to your 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.
Disclosure Accounting: You have the right to receive a list of instances in which we or our
business associates disclosed your medical information for purposes other than treatment, payment, health care
operations, as authorized by you, and for certain other activities, since April 14, 2003. You must make a request
in writing to request a listing of disclosures. You may obtain a form to request the accounting by using the
contact information at the end of this notice. If you request this accounting more than once in a 12-month period,
we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the
information listed at the end of this notice for a full explanation of our fee structure.
Restriction: You have the right to request that we place certain restrictions on our use or
disclosure of your medical information. We are not required to agree to these additional restrictions, but if we
do, we will abide by our agreement (except in an emergency). Any agreement to additional restrictions must be in
writing. You may obtain a form to request additional restrictions on the use or disclosure of your medical
information by using the contact information listed at the end of this notice. We will not be bound to the
restrictions unless our agreement is signed by you and the appropriate hospital representative.
Confidential Communication: You have the right to request that we communicate with you about
your medical information by alternative means or to alternative locations. For example, you might request that we
contact you at work or by mail. You must make your request in writing. You may obtain a form to request
alternative communications by using the contact information listed at the end of this notice. We must accommodate
your request if it is reasonable, specifies the alternative means or location, and provides satisfactory
explanation how payments will be handled under the alternative means or location you request.
Amendment: If you feel that medical information we have about you is incorrect or incomplete,
you may ask us to amend the information. Your request must be in writing, and it must explain why the information
should be amended. You may obtain a form to request an amendment by using the contact information listed at the
end of this notice. We may deny your request if we did not create the information you want amended and the
individual who provided the information remains available or for certain other reasons. If we deny your request,
we will provide you a written explanation. You may respond with a statement of disagreement to be attached to the
information you wanted amended. If we accept your request to amend the information, we will make reasonable
efforts to inform others, including people you name, of the amendment and to include the changes in any future
disclosures of that information.
Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail),
you are entitled to receive this notice in written form. Please contact us using the information listed at the end
of this notice to obtain this notice in written form.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us using
the information listed at the end of this notice.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made
about access to your medical information or in response to a request you made to amend or restrict the use or
disclosure of your medical information or to have us communicate with you by alternative means or at alternative
locations, you may complain to us using the contact information listed at the end of this notice. You also may
submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the
address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your medical information. We will not retaliate in any way if you
choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact: PRIVACY OFFICER
Telephone: 304-235-2500
Address: 859 Alderson Street, Williamson, WV 25661
THIS NOTICE IS YOUR COPY TO RETAIN FOR ANY FUTURE QUESTIONS OR CONCERNS REGARDING THE USE OF YOUR
PROTECTED HEALTH INFORMATION.
Please sign the Acknowledgment to signify your receipt and understanding of this document for our records.
Thank You.