Columbus Regional Healthcare System
NOTICE OF PRIVACY PRACTICES
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.

WHO WILL FOLLOW THIS NOTICE.

This notice describes Columbus Regional Healthcare System’s  (hereafter referred to as the “Hospital”) practices including the Hospital affiliated clinics and that of:

• Any independent health care professional who is on the Medical Staff and under contract and authorized to enter information into your medical record.
• All departments and units of the Hospital.
• Any member of a volunteer group we allow to help you while you are in the Hospital.
• All employees, staff and other hospital personnel.
• All students or trainees.
• All these persons, entities, sites and locations follow the terms of this notice.  In addition, these persons, entities, sites and locations may share medical information with each other for your treatment, payment or the Hospital operations purposes and the purposes described in this notice.  The independent health care professionals who provide care at the Hospital and who have agreed to follow the terms of this Notice are not employees or agents of the Hospital, and the Hospital is not responsible for how they fulfill their professional responsibilities.

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 at the Hospital.  Your health information is contained in a medical record that is the physical property of the Hospital.  We need this record to provide you with quality care and to comply with certain legal requirements.

This notice applies to all of the records of your care and billing for care that are created at the Hospital, whether made by the Hospital personnel or your independent personal doctor or other independent health care personnel.  Your personal doctor or other independent health care personnel treating you may have different policies or notices regarding confidentiality and disclosure of your medical information that is created in their office or other location outside the Hospital. 

This notice will tell you about the ways in which the people listed above 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:

• make sure that medical information that identifies you is kept private; 
• give you this notice of our legal duties and privacy practices at the Hospital with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose medical information.  For each category of uses or disclosures we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the 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 who are members of the Hospital’s medical staff and to 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.  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 also may share medical information about you in order to coordinate what you need, such as prescriptions, lab work and x-rays.  We also may need to disclose medical information about you to people outside the Hospital who may be involved in your medical care before or after you leave the Hospital, such as family members, or others who provide services (such as home health agencies) that are part of your care.  We will only disclose medical information about you to people outside the Hospital, who are not currently involved in your care with your consent, or if such disclosures are required or permitted by law. 
• For Payment.  “Payment” could include the Hospital’s efforts to obtain reimbursement from you or a responsible third party for services that the Hospital has provided to you.  The Hospital may use or disclose your individually identifiable information for its own payment or for the payment and activities of another health care provider or health plan or health plan clearinghouse.   For example, we need to give your insurance company or health plan information about surgery you received at the Hospital so your insurance company or health plan will pay us or reimburse you for the surgery.  We may also tell your insurance company or health plan about a treatment you are going to receive to obtain prior approval or to determine whether your insurance company or health planwill cover the treatment.  To obtain payment, we will only disclose medical information about you to people outside the Hospital with your consent, or if such disclosures are required or permitted by law. 
• For Health Care Operations.  Our staff and business associates may use and disclose medical information about you for Hospital operations.  These uses and disclosures are necessary to run the Hospital and make sure that all of our patients receive quality care.  For example, we may use medical information to review our treatment and services and to evaluate the qualifications and performance of our staff and medical staff in caring for you.  We may also combine medical information about many Hospital patients to decide what additional services the Hospital should offer, what services are not needed, and whether certain new treatments are effective.  We may also disclose information to Hospital personnel, doctors, and students for review and learning purposes.  We may also combine the medical information we have about you and other patients with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer.  We will remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who you are.  With your consent we will only disclose medical information about you that identifies you to people outside the Hospital who are not involved in Hospital operations or if such disclosures are required or permitted by law. 
• 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.  We will leave a message for you at any telephone number you give us stating the time of the appointment and the name of the person with whom you have the appointment unless we have agreed in writing  to handle appointment reminders differently.
• Fundraising Activities.  The CRHS Foundation may use your demographic information to engage fundraising activities.  The Foundation does not sell protected health information to outside organizations and takes steps to ensure that only authorized business associates who need to know see your demographic information.         
  You may receive information from the CRHS  Foundation.  If you do not want to get this information, contact the CRHS Foundation at 910-642-9303, send an email to tpriest@crhealthcare.org or write us at CRHS Foundation, 500 Jefferson Street, Whiteville, NC 28472.  Please include your full name and address in all communications. 
• Business Associates    There are some services provided in the Hospital through contracts with business associates which are vendors, professionals and others who perform some treatment, payment or health care operation function on behalf of the Hospital or who otherwise provide services and have access to or use your protected health information.  Examples include physician services for anesthesiology, radiology, in the emergency department and for certain laboratory tests.  When these services are contracted, we disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered.  To protect your information, however, we require the business associate to appropriately safeguard your information by requiring that they enter into an appropriate agreement with the Hospital. 
• The Hospital Directory.  Unless you tell us otherwise,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 also 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 don’t ask for you by name.  This is so your family, friends and clergy can visit you in the Hospital and generally know how you are doing.  If you do not want anyone to know this information about you, if you want to limit the amount of information that is disclosed, or if you want to limit who gets this information, you may indicate your choice in writing during registration on the Hospital’s Patient Directory Instructions Form. 
• Notification.  Unless you object in writing, health professionals, using their best judgment, may use or disclose information to notify or assist in notifying a family member, personal representative, or any person responsible for your care, your location and general condition.  If you are unable to object, we may exercise our professional judgment to determine if a disclosure is in your best interest and disclose only information that is directly relevant to the person’s involvement with your health care.
•  Disaster Relief.   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.  You can object to these disclosures by telling us that you do not wish any or all individuals involved in your care to receive this information.  If you are not present or cannot agree or object, we will use our professional judgment to decide whether it is in your best interest to disclose relevant information to someone who is involved in your care or to an entity assisting in a disaster relief effort.
• 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 received one medication to those who received another for the same condition.  All research projects, however, are subject to a special approval process and will require your written authorization if the researchers will know who you are.  Medical information about you that has had all identifying information removed may be used for research without your authorization. 
• 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.  When death is imminent we are required by law to release medical information concerning patients to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary for them to determine organ or tissue donation potential.   If you are an organ or tissue donor, we are also required by law to provide medical information about you after your death to the entity who receives the organ or tissue donation.
• Workers’ Compensation.  Without your consent we may release medical information about you for workers’ compensation or similar programs under appropriate circumstances.  These programs provide benefits for work-related injuries or illness.
• Public Health Risks.   Without your consent 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 suspected abuse or neglect as required by law;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using; and
  • 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.
• Health Oversight Activities.  Without your consent 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 a dispute, we may disclose medical information about you in response to a court or administrative order.  We also may disclose medical information about you in response to a subpoena or other lawful process by someone else involved in the dispute by furnishing your medical records or information under seal to the court.  The copies of your medical record under seal may only be opened by the parties to the case or their attorneys unless a judge orders otherwise.
• Coroners, Medical Examiners, and Funeral Directors.  Without your consent 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. 
• Security, Intelligence Activities, and Protective Services.   Without your consent we may release medical information about you to authorized federal or state officials for intelligence, counterintelligence, and other governmental activities authorized by law.  Without your consent we may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or 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 without your consent medical information about you to the correctional institution or law enforcement official with custody of you on behalf of the correctional institution if necessary:  (1) for the Hospital to provide you with health care; (2) to protect your health and safety; (3) to obtain payment; or (4) for operations of the Hospital.  If you are in the custody of the Department of Correction (“DOC”) and the DOC requests your medical records, we are required to provide the DOC with access to your records.
• Behavioral Health Care.  Regardless of the other parts of this Notice, any information relating to alcohol and drug treatment or other behavioral health care treatment, including psychotherapy notes, will not be disclosed outside the Hospital except as authorized by you in writing, pursuant to a court order, or as required by law. 
• Minors.
  A parent, guardian, or other person with authority to act in loco parentis has authority to have access to and decide the use and disclosure of protected health information concerning a minor patient, except when:
  1. A custody order or agreement provides otherwise;
  2. A court order provides otherwise;
  3. There is a reasonable basis to suspect abuse or neglect of the minor and providing such information or authority to the parent, guardian, or other person acting in loco parentis is reasonably believed to present a risk of injury or harm to the minor;
  4. The minor has the right to obtain health care on his or her own behalf as is permitted in the following cases:
     1. For outpatient diagnosis or treatment of emotional/psychological illness;
     2. For diagnosis or treatment of pregnancy (not abortion);
     3. For diagnosis or treatment of drug or alcohol abuse;
     4. For diagnosis or treatment of sexually transmitted diseases;

        In these circumstances, however, the Physician may notify
        these individuals if in the physician’s opinion the notification is essential to your life or health,  In addition, the physician may give such information if your parent, legal guardian, person standing in loco parentis or legal custodian contacts the physician concerning your treatment.

     5. The parent or guardian has  agreed that such information will be confidential between the minor and the Hospital.

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 receive a copy of medical information that may be used to make decisions about your care, unless your treating physician determines that providing you with such information would be injurious to your well-being.  When we deny your request to inspect and receive a copy of your medical information on this basis, 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 do what this reviewer decides.
• To inspect and receive a copy of medical information that may be used to make decisions about you, you must submit your request in writing to the Hospital’s Director of Health Information Management.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request and may collect the fee before providing the copy to you. 
• 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 the Hospital. 

To request an amendment, your request must be made in writing and submitted to the Hospital’s Director of Health Information Management.  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 created by a provider other than the Hospital, unless the provider who created the information is no longer available to consider or make the amendment;
• Is not part of the medical information kept by or for the Hospital;
• Is not part of the information which you would be permitted to inspect and copy; or
• Has been determined to be accurate and complete.

• Right to an Accounting of Disclosures.  You have the right to request a list of certain disclosures we have made of medical information about you.   To request this list or accounting of disclosures, you must submit your request in writing to the Hospital’s Director of Health Information Management.  Such an accounting may not include disclosures made to carry out treatment, payment or health care operations, to create an accurate patient directory or notify persons involved in your care, to ensure national security, to comply with the authorized requests of law enforcement, to inform you of the content of your medical records, or those disclosures which you have previously authorized pursuant to a validly executed authorization form.  Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003.  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 costs 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 costs are incurred.  We will collect the fee before providing the list to you. 
• Right to Request Restrictions.  Except where we are required to disclose the information by law, you have the right to request a restriction or limitation on the medical information we use or disclose about you to individuals or entities outside of the Hospital.  You also have the right to request a limitation on the medical information we disclose about you to someone who is involved in your care or the payment for your care.  However, the law does not require the Hospital to agree to the requested restrictions unless the restriction request is a reasonable restriction on communication.

If we do agree, we will comply with your requested restriction unless the information is needed to provide you emergency treatment.  Except as required by law, we will only disclose your confidential medical information to persons outside the Hospital who are not currently involved in your care at the Hospital, with and in accordance with your authorization.

To request restrictions, you must make your request in writing to the Hospital’s Director of Health Information Department.  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, disclosures to your spouse.

• Right to Request Alternative Type of Communication.  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, or at a mailing address other than your home address. 

To request certain types of communications, you must make your request in writing to the Hospital’s Patient Registration Department and specify how or where you wish to be contacted.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  

• Right to a Paper Copy of This Notice.  You have the right to a paper copy of this notice or any revised notice.  A copy of this may be obtained from the Patient Access Department of the Hospital.  

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 remain in effect for each subsequent visit unless changed.  If the notice changes, a copy will be available to you upon request or at our website.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the Department of Health and Human Services.   To file a complaint with the Hospital, contact the Compliance/Privacy Officer at 910-641-8347.   Please send your complaint in writing to the following address:

                  Attention:  Compliance/Privacy Officer
                  Columbus Regional Healthcare System   
                  500 Jefferson Street 
                  Whiteville, NC   28472.

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 will be made only with your written permission or as required by law.  If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  Your revocation will be effective as of the end of the day on which you provide it in writing to the Health Information Department.  If you revoke your permission, we will no longer use or disclose medical information about you for the purposes that you had authorized in writing.   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.

If you have any questions about this notice, please contact the Compliance/Privacy Officer at 910-641- 8347.