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.

Cloud County Health Center
1100 Highland Drive
Concordia, Kansas 66901

This Notice of Privacy Practices is effective as of 04/14/2003.

UNDERSTANDING YOUR HEALTH INFORMATION -- HOW IT IS USED AND HOW IT MAY BE SHARED WITH OTHERS:  There are laws that require we give this Notice to you about what we do with your health information. This Notice is about the health information we keep while you are receiving care in the Hospital.

WHAT IF YOU HAVE QUESTIONS ABOUT THIS NOTICE?  If you do not understand this Notice or what it says about how we may use your health information, please contact: The  Office of Privacy Officer.

WHAT IS YOUR HEALTH RECORD OR HEALTH INFORMATION?  When you go to a hospital, doctor, or other health care provider, a record is made that tells about your treatment.  This record will have information about your illnesses, your injuries, signs of illness, exams, laboratory results, treatment given to you, and notes about what might need to be done at a later date.  Your health information could contain all kinds of information about your health problems.  The hospital keeps this health information and can use this information in many different ways.  What we do with your health information and how we can use and share this information is what the rest of this Notice describes.

WHAT IS THE RESPONSIBILITY OF THE HOSPITAL WHEN IT COMES TO YOUR HEALTH INFORMATION?  The law requires that this Hospital must do the following when it comes to handling your health information:

• Keep your health information private, only giving it out when allowed by law to do so
   

• Explain our legal duty and our rules about keeping your health information private to you
   

•  Follow the rules given in this Notice
   

•  Let you know when we can't agree with a request or demand you may make to restrict the sharing of your health information with others.
   

•  Help you when you want your health information sent in a different way than it usually is sent or to a different place than it usually is sent.

We will not give out your health information without your permission except in certain cases explained in this Notice.  There are laws that say we can give out your health information to others without your permission.  The Hospital will follow these laws.  The Hospital can give out your health information electronically (over computer networks, for example) or by facsimile.

WHAT ARE YOUR HEALTH INFORMATION RIGHTS?  Your health information is the property of the doctor or hospital that wrote it.  The information contained in your health information belongs to you.  You have certain rights concerning this health information.  The following is a list explaining your rights:

You Have the Right to Look at Your Health Information and You Can Get a Copy of This Information Which May Be Used to Help With Your Care.  This information will usually include medical and billing records.  Your information will not have psychotherapy notes and information that is made to be used in a court proceeding or information covered by special laws.  If you want to see your health information and get a copy of your health information, you must write a request to the Contact Person.  If you are disabled or ill, you can make this request over the phone or in person. You may be charged for copies and mailing.  We may refuse your request for your health information.  If we refuse you, you will be told in writing.  If we refuse, you can have the decision to not allow you to see your health information reviewed.  A neutral person will review your request and we will do what they say.

You Have the Right to Ask That We Make Changes to Your Records.  If you feel that your health information is not complete or wrong, you can ask that we change it. You can ask that we make a change to your health information for as long as we have it.  If you want to make a change to your health information, you must give a good reason for the change.  If you don't put your request for a change in writing and give a good reason, we may not allow the change to be made.  We may also refuse your request for change for the following reasons: (1) the information was not created by this Hospital; (2) it is not a part of the health information kept by or for the Hospital; (3) it is not information you are permitted to see or copy; or (4) it is accurate and complete.

You Have a Right to a List of Individuals to Whom We Gave Your Health Information.  To request a list of names to whom we gave your health information, you must write a request to the Hospital.  You have to include a time period in your request.  The time period can be no longer than six (6) years and you cannot request a list of names that covers the time period before April 14, 2003. You should tell us in what form you want the list (paper copy, electronically, or some other form). You can have one list each year at no cost.  You will be charged for any additional lists within the year period.

You Have the Right to Ask for a Restriction.  You have the right to ask that we restrict or limit some part of your health information.  You can also ask that we limit information about you to a person who is giving you care or paying for care like a family member or friend. For example, you could ask that we not give out information about some treatment you have had or that we not tell certain people specific information in your health information.  We are not required to agree to your request. There is a person called a Privacy Officer who is the only one who can agree to your request.  We will notify you if the restriction will be applied or not. How to make a request. If you want to restrict or limit the information in your health information that we give out, you must put your request in writing.  Tell us (1) what information you want to limit; (2) whether you want to limit our use of your health information, our giving out your health information, or both; and (3) whom should not receive the health information.

You Have the Right to Ask for Privacy in Communications.  You have the right to ask that we communicate with you about your health information only in a certain way or at a certain location.  An example would be asking that we only contact you at work or only by mail.  To ask for privacy in communications, you must make your request in writing to the Hospital.  We will attempt to grant all reasonable requests and although you are not required to give reasons for your request, we may ask you.  Be sure to be specific in your request about how and where you wish to be contacted. We may charge you for this privacy request and if you fail to pay, the privacy communication will be stopped.

You Have the Right to a Paper Copy of This Notice.  You have a right to a copy of this Notice at any time. You can request a copy from the Hospital.

HOW WILL WE USE AND GIVE OUT YOUR HEALTH INFORMATION?    The Hospital can use and disclose your health information without your permission. The following is a list of when we can do this:

For Treatment.  We may use your health information to provide you with medical treatment or services.  We may give your health information to other doctors, nurses, technicians, medical students, or other staff personnel who are involved in taking care of you.  For example, a doctor treating you for a broken bone 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 meals. Different departments of the Hospital may share your health information in order to coordinate the different services you need, such as prescriptions, lab work, and x-rays.  We also may disclose your health information to treaters outside the Hospital who may be involved in your treatment while you are in the Hospital or after you leave the Hospital. 

For Payment.  We may use and give out your health information about the treatment you receive here in the Hospital so that you or the insurance company or even a third party can be billed.  For example, we may give your health insurance company information about your surgery so that your insurance plan will pay us or pay you for the surgery. Sometimes we may have to tell your insurance company before your surgery to get an approval from them so that they will cover the surgery.

For Health Care Operations.  We may use or give out your health information to make sure we are giving you the best care possible.  For example, we may use your health information to see how well our staff takes care of you.  We may combine your health care information with other individual´s information to decide on additional services we should offer to our patients and to see if new treatments really work.  We may also give your health care information out to doctors, nurses, technicians, medical students, and other hospital workers for their review and for their studies.  We may also combine information we have with other hospitals to compare and see how we are doing and how we can provide better treatment.  We may remove information from your health information so others who look at your health information cannot see your name.  This way, we can study information without knowing the individual names.  Here are some other reasons we may use and disclose your health care information: to see how well we are doing in helping our patients; to help reduce health care costs; to develop questionnaires and surveys; to help with care management; to make sure we are doing our job well and successfully; to better train people so they can get the skills they need to best perform their special skills; to help insurance companies better serve you in their policy making; to help those that check up on hospitals and ensure that we are doing our job correctly; to help us plan and develop the business part of health care including fund-raising and advertising so that we are profitable.  For example, if you have surgery we may use your surgery information to see how long you were in the operating room so we can see how to schedule operations better.

Appointment Reminders.  We may give out your health information to contact you, a relative, or a friend to remind you that you have an appointment at our Hospital.  We may leave a message on your answering machine or voice mail system unless you tell us not to.

Treatment Alternatives.  We may use or give out your health information to let you know about treatments that may be offered to you so you can make good choices about your health care.

Health Related Benefits and Services.  We may use and give out health information to tell you about health benefits or services that may be of interest to you.

Fund-raising Activities.  We may use your health information to contact you to help our Hospital raise money.  We may also give out your health information to a foundation so they can help the Hospital raise money.  For fund-raising activities, we will only give out basic contact information such as name, address, phone number, and the dates you were treated at the Hospital. If you do not want the Hospital to contact you for its fund-raising purposes, you must tell the Hospital.

Hospital General Public Disclosure.  We may give out limited information about you, which will be available to the public.  While you are here at the Hospital as a patient, the information we give out may be your name, room number in the Hospital, and your general condition (for example, fair, stable, etc.) and your religion.  All the above information except your religion can be given out to the public who ask for you by name.  Your religion may be given to a minister, priest, or rabbi even if they don´t ask for you by name.  This is so your relatives, friends, and religious persons can visit you in the Hospital. If you do not want this information given out, you must write the Hospital or by writing this on the admission form.

Individuals Involved in Your Care or Payment for Your Care.  We may give out health information about you to one of your friends or family members who is in some way involved in your medical care.  We may give out your health information to another person who is helping pay for your care.  We may tell your family or friends about your condition and that you are in the Hospital.   Also, we may give out your health information as part of a disaster relief effort so your family knows about your condition and location.   How much of your health information we give out to another person will depend on how much they are involved in your care.

Research.  Sometimes for special reasons, we may give out your health information to researchers who want to do scientific research about how well certain drugs or treatments work.  If a researcher wants to do a study involving you and your information, we will follow steps to make sure research is approved that will benefit all people.  The research must be worthwhile.  We may give out health information to researchers to help them find the patients they need for their research study.  The information we give them will usually not leave the Hospital. If a researcher wants your name, address, and other information about you, we will almost always ask permission from you before they contact you.

As Required by Law.  Federal, state, and local laws may require us to give out certain kinds of health information.  Things like wounds from weapons, abuse, communicable diseases, and neglect are examples of such information and we do not need your permission to give out this information.

To Avoid a Serious Threat to Health or Safety.  We may use or give out your health information if your health and safety is at risk or in danger.  We also will give out your health information if the health of the public or another individual is at risk.  If we give this information out, it will be given to someone who may be able to prevent the threat.

Organ and Tissue Donation.  If you are an organ donor, we may give out your health information to people who deal with organ collection, eye or tissue transplants, or to a donation bank.  We give your information to these people to make sure organ or tissue donation or transplants can be made.

 Military and Veterans.   If you are a member of the armed forces, we may give out your health information as required by those military authorities in command.  If you are a member of the military of another country, we may release your health information to the authority in command in your country. 

 Worker's Compensation.  If you are involved in an injury that happens while you are at work, we may have to give out your health information so your employer can pay your medical bills.  This is called worker's compensation.

Public Health Risks.  We may give out your health information without your permission if there is a danger to the public's health.  Some general examples of these dangers: to avoid disease, injury or disability; to report births and deaths; to report child abuse and neglect; to report reactions to drugs and other health products; to report a recall of health products or medications; to tell a person they have been exposed to a disease or may get a disease or spread the disease; to tell a government authority if we believe a patient has been abused, neglected, or the victim of violence; to let employers know about a workplace illness or workplace safety; to report trauma injury to the state.

Health Oversight Activities.  We may give out your health information without your permission to a special group who checks up on hospitals to make sure they’re following the rules.  These special groups investigate, inspect, and license hospitals.  This is necessary for our government to know about our hospitals and that they are following the rules and the laws.

Lawsuits and Disputes.  We may give out your health information if you are involved in a lawsuit or dispute.  If a court orders that we give out your health information even if you are not involved in a lawsuit or dispute, we may also give out your health information. Other reasons that may cause us to release your health information would be if there was an order to appear in court, a discovery request, or other legal reason by someone else involved in a dispute.  There must be an effort made to tell you about this request or an order to make sure that the information they want is protected.

Law Enforcement.  We may give out your health information if asked for by a police official for the following reasons: for a court order, subpoena, warrant, or summons; to find a suspect, fugitive, witness, or missing person; to find out about the victim of a crime if we cannot get the persons ok; about a death we believe may be the result of a crime; about some crime that happens at the Hospital; in emergencies to report a crime, the place where the crime happened, the victim of the crime, or the identity, description or whereabouts of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors.  We may give out your health information to a coroner or medical examiner to identify a person who has died or determine the cause of death.  We may also give out health information to funeral directors so they can carry out their duties.

 National Security and Intelligence Activities.  We may give out your health information to federal authorities for intelligence, counter-intelligence, and other situations involving our national safety.

 Protective Services for the President and Others.  We may give out health information about you to federal officials so they can protect the President or other officials or foreign heads of state or so they may conduct special investigations.

Inmates.  If you are an inmate of a prison or placed under the charge of a law enforcement official, we may give out your health information (1) to the prison to provide you with health care; (2) to protect the health and safety of you and others; or (3) for the safety of the prison.

Redisclosure.  When we use or give out your health information, it may contain information we received from other hospitals and doctors.

GIVING PERMISSION AND REVOKING PREVIOUS PERMISSION TO USE OR DISCLOSE YOUR HEALTH INFORMATION:  Except as stated in this Notice, in order for us to give out your information, you have to complete a written authorization form.   If you want, you can later choose not to let us give out your health information.  You can do this at any time.   Your request to later stop permission to give out your health information must be in writing and sent to the Hospital.  It is not possible for us to take back any information we have already given out about you that we made with your permission.

WHAT SHOULD YOU DO IF YOU HAVE A COMPLAINT CONCERNING YOUR HEALTH INFORMATION?  If you believe your right to privacy has been violated, you can write a complaint and give it to the Hospital or the U.S. Department of Health and Human Services.  To find out how exactly to file a complaint with either the Hospital or the U.S. Department of Health and Human Services, ask the Hospital.  THERE IS NO PENALTY FOR FILING A COMPLAINT.

IF CHANGES ARE MADE TO THIS NOTICE: We will give you a copy of this Notice the first time we treat you and whenever you request it. We have the right to change this Notice at any time without letting people know we are going to change it. We have the right to make the changed Notice apply to health information we already have about you as well as any information we receive in the future.  We will post a copy of the newest Notice in the Hospital.  You will find the date the Notice takes effect at the top of the first page below the title.  You can get a copy of this Notice at any time by contacting the Contact Person listed above.  You may get a copy of the current Notice each time you are admitted to the Hospital for treatment.

 POLICY 32.  ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

 1.            Hospital will secure a written acknowledgment that the patient has received a copy of its Notice of Privacy Practices no later than the first service delivery date.  Acknowledgments that are obtained prior to or after the first service delivery (because of emergency or extenuating circumstances) should be included in the patient’s health information.

 2.            Acknowledgment of receipt of the Notice of Privacy Practices may be captured electronically.  The electronic receipt may be electronically stored with the patient’s electronic health information, or reduced to hard copy and placed in the patient’s health information.  Acceptable mechanisms include storing the verification of receipt notice, requesting the patient confirm electronic receipt and storage of the confirmation.  Whenever electronic receipt cannot be confirmed, Hospital will make and document other good faith efforts to obtain acknowledgment by alternate means (for example, physical delivery at first service, mail delivery).

 3.            If a written acknowledgment is not obtained prior to treatment due to an emergency treatment situation, the Hospital must make good faith efforts to secure the acknowledgment as soon as practicable (for example, if the patient is treated in the emergency department and transferred prior to providing an acknowledgment, the Hospital can mail the Notice of Privacy Practices and acknowledgment to the patient asking the patient to sign and return the acknowledgment.  These efforts should be documented.  See: Acknowledgment Documentation Form).

 4.         If the Hospital is unable to secure a written acknowledgment then the Hospital must document its good faith efforts to obtain the acknowledgment.  See: Acknowledgment Documentation Form.

 5.         If a patient fails to properly acknowledge receipt of the Notice of Privacy Practices on the Treatment Authorization and Acknowledgment form, a copy of the form should be mailed to the patient for completion. The original remains in the patient’s health information.  The returned copy should be included in the patient’s health information next to the original.  An Attempt to Obtain Acknowledgment Documentation Form should be completed.

 6.         Acknowledgments and Acknowledgment Documentation Forms will be maintained in the patient’s health information.

Cloud County Health Center

Concordia, Kansas

Patient Name:_______________________________      Date of Birth_________

Medical Record No.:________________           Admission Date:__________________

                            TREATMENT AUTHORIZATION AND PRIVACY ACKNOWLEDGMENT

 Cloud County Health Center, including its acute care, swing bed unit, long-term care unit, emergency department, outpatient surgery and outpatient departments is hereinafter referred to as "Hospital".

1.  CONSENT FOR TREATMENT:  I consent to x-ray examinations, laboratory procedures, anesthesia, medical or surgical treatment, hospital services, and/or other services rendered under the general and special instructions of my attending or consulting physicians.  I understand that my treatment is under the control of my attending physicians, their assistants or designees.  If admitted, I understand that if I desire private duty nursing care, it is agreed that such must be arranged by myself or my family and the Hospital shall be released from any and all liability arising from such care.  I understand that if further diagnostic studies or treatment procedures that are considered major in nature, such as an operation, are required, I will be asked to give specific consent for these prior to them being carried out.  I understand that the practice of medicine and surgery is not an exact science, and acknowledge that no guarantees have been made to me as to the results of care, treatment, and the provision of medical services.

3.     CONSENT FOR BLOOD/BODY FLUID TESTING: In the event that a health care worker or emergency response person(s) is suspected to have had exposure to my blood and/or body fluids or if it is likely that a health care worker or emergency response person(s) is exposed to my blood and/or body fluids, due to my illness or an uncommon rare disease, I consent to have the Hospital determine by serological testing whether or not my blood contained contagious viruses.  I understand that the information obtained from such tests will only be disclosed as necessary to adequately protect my own health and the health of my family, as well as the health of those health care personnel or emergency response person(s) who may have been or become involved in my treatment.

4.     CONSENT TO DISPOSAL OF TISSUE/FLUIDS/SPECIMENS.  I agree that the Hospital may utilize, destroy, or dispose of any tissues, fluids, or specimens taken from me during treatment.

5.     AGREEMENT TO PAY FOR SERVICES:  I agree, whether I sign this as an agent or as the patient, that in consideration of services to be rendered to me, I hereby individually obligate myself to pay the charges of the Hospital in accordance with its regular rates and terms.  However, I am aware that any patient arriving at the facility will have a medical screening examination performed regardless of the ability to pay.

6.     ASSIGNMENT OF INSURANCE BENEFITS:  I hereby assign my insurance benefits otherwise payable to me to be paid directly to the Hospital.  I understand that I am financially responsible for charges not covered by this assignment and further agree to guarantee full payment of all charges not covered by third-party payers.  If I do not pay the amount due as I agreed, I agree also to pay the reasonable costs of collection, including but not limited to attorney fees and collection agency fees.

7.     MEDICARE/MEDICAID BENEFITS:  I authorize the Hospital to release to Medicare and/or Medicaid, to the Social Security Administration and/or its intermediaries or carriers, and to any peer review organizations, any information needed for this or a related Medicare and/or Medicaid claim.  I request payment of authorized benefits to be made on my behalf to the Hospital for services furnished to me, and to the physicians involved for their services, including those physicians/specialists doing their own billing, while I was a patient in the Hospital.

8.     PERSONAL VALUABLES/BELONGINGS:  I have elected/refused (circle one) to place valuables (i.e., money, jewelry, credit cards, or other articles of unusual value, etc.) into the Hospital's safekeeping during my period of hospitalization.  Dentures, glasses, hearing aids, my garments and essential daily necessities are considered personal belongings.  I understand that I am, at all times, responsible for the safekeeping of my personal belongings. I understand that the Hospital CANNOT AND WILL NOT accept responsibility for loss of any of my valuables/belongings, if they are lost or misplaced.

9.     DENTURES: The Hospital provides denture cups for me if I require them.  I will take precautions to be sure my dentures are properly kept and cared for and they will be kept in the denture cup at all times when I am not wearing/using them.

10. NOTIFICATION TO PATIENTS:  Certain diseases and conditions, including cancer, are required by law to be reported.  I understand that the Hospital will comply with this by submitting the necessary information on my condition and myself to a centralized registration point.

11. CONTRABAND WEAPONS/DRUGS:  I agree that should the Hospital find contraband weapons and/or nonprescription drugs not sold over-the-counter within my possession, these items will be confiscated and the police will be contacted.

12.  USE OF APPLIANCES:  I hereby agree that in using any and all electrical appliances in my room, not owned by or under the control of the Hospital while a patient in the Hospital, I do so at my own risk and hereby absolve the Hospital from any and all responsibility for injuries or property damage which may result from any use of said appliance.

13. PROVIDER NON-DISCRIMINATION ACT:  I understand that this is an equal opportunity institution. There is no discrimination because of race, color, religion, natural origin, age, sex, handicap, or inability to pay.

14. MEDICARE/TRICARE PATIENTS ONLY:  (only for acute care) I have received a copy of "An Important Message from Medicare/Tricare" and understand my rights as described in that document.

15. PATIENT RIGHTS INFORMATION: I have reviewed/received Patient Rights and Responsibilities and understand my rights as described in that document.

16. NOTICE: Your health information related to work-related illnesses or injuries or to medical surveillance of the workplace may be disclosed to your employer.

17. ADVANCE DIRECTIVE INFORMATION: (Complete this section for acute, ambulatory surgery, observation and swing bed/respite patients only.)

   YES         NO

 PATIENT/PERSONAL REPRESENTATIVE MUST COMPLETE BY SIGNING OR INITIALING

 18.  CONSENT TO DISCLOSE GENERAL INFORMATION.  I understand that my name, location in hospital, and general condition may be provided to any person asking about me by name, and to members of the clergy, my family, individuals involved in my health care, for disaster relief efforts, or as required by law.  I do _____  do not _____give consent for this information to be disclosed.

______________________________________

(Patient/Personal Representative Signature or Initial)

 19.  ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES.   I hereby acknowledge that I have received a copy of the Hospitals Notice of Privacy Practices.                         

______________________________________________

(Patient/Personal Representative Signature or Initial)

 I certify that I have read and fully understand this document and that I have received a copy of it.  I, as the patient/personal representative, agree to sign this document indicating that I agree with all of its terms and statements.

___________________________________________________________________________ 

Date                         Patient/Personal Representative                             Relationship to Patient     

_____________________________________________________________________

Date                                                     Signature, Witness                  

ACKNOWLEDGMENT FORM (Provide to patient at first delivery of service date.   May also be provided by mail.)

  RESOURCE:   ATTEMPT TO OBTAIN ACKNOWLEDGMENT DOCUMENTATION FORM

(to document good faith efforts to obtain acknowledgment)

 Cloud County Health Center

1100 Highland Drive

Concordia, Kansas 66901

   ATTEMPT TO OBTAIN ACKNOWLEDGMENT DOCUMENTATION FORM

 Name of Patient: ________________________________________________________________

 Medical Record Number: _________________________________________________________

 Date of Service: ________________________________________________________________

 Attempts to obtain written acknowledgment (include description and dates of attempts): ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

  Reason written acknowledgment was not obtained because:______________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 Signature: ____________________________________________

 Date: _________________________________________

RESOURCE:    ACKNOWLEDGMENT LETTER TO PATIENT

(send to patient with Notice of Privacy Practices)

Cloud County Health Center
1100 Highland Drive
Concordia, Kansas 66901

[Date]

 [Mr./Ms. DOE]

[1128 North THX Blvd.]

[Concordia, KS 66666]

Dear [Mr. /Ms. DOE]:

Enclosed is a copy of the Hospitals Notice of Privacy Practices, which explains how the Hospital maintains the privacy of your health information, and your rights.  Please read it very carefully.

A form to acknowledge that you have received the Notice is enclosed.  Please return it to us as soon as possible.

Sincerely,

[Signed C.T.B.]

[Printed C. T. B., title]

Enclosure: Acknowledgment Form

  YES                        NO