Patient Privacy Notice

MEMORIAL HOSPITAL OF NORTH CONWAY, NH

Effective Date: July 7, 2009

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Policy and responsibilities Regarding Your Health Information

At the Memorial Hospital (the “Hospital”), we are committed to maintaining the confidentiality of your health information. Your health information in our records includes both medical and personal information such as your name, address, date of birth, social security number and insurance information. This Notice describes how your health information may be used and disclosed. It also describes your rights and certain obligations we have regarding the use and disclosure of your health information.

This Notice applies to all of the records of your care generated at or by the Hospital whether made by Hospital personnel, your personal doctor, specialists involved in your treatment or other caregivers. Your doctors who are not part of this hospital may have different policies regarding the use and disclosure of your health information in that doctor’s office or clinic.

We are required by law to give you this Notice describing our privacy practices, to make sure that health information that identifies you is kept private and to follow the terms of this Notice. If you have any questions, please contact us at the telephone number or address listed at the end of the Notice.

Who Will Follow This Notice?

The Hospital is a clinically integrated care setting in which patients typically receive health care from more than one health care provider. This means that your care may be provided by Hospital staff members, physicians and other practitioners and/or physicians and other practitioners from other independent practices but who have privileges to provide care at the Hospital. The physicians and other practitioners who are independent will have their own health information practices in their own offices, but they have agreed to abide by the practices described in this Notice for health information in your records at the Hospital.

The practices described in this Notice will be followed by the Hospital and: (1) any health care professional who provides care for you at the Hospital; (2) any volunteer at the Hospital; and (3) all employees of the Hospital. These entities and practitioners may share health information with each other for treatment, payment or health care operations purposes described in this Notice.

How We May Use and Disclose Health Information About You

The Hospital and the health care practitioners described above may share health information about you in order to provide services to you and to be paid for the services rendered to you. Following are descriptions of different ways your health information may be used and disclosed. These descriptions will not include every use or disclosure. 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 your health information to provide treatment or services, coordinate or manage your health care. We may disclose health information about you to doctors, nurses, technicians, or other personnel who are involved in caring for you. For example, different departments and practitioners may share health information in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside the Hospital who may be involved in your medical care, such as, for example, home health agencies or physical therapists.

For Payment. We may use and disclose your health information so that treatment and services you receive at the Hospital may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a medical procedure you received so your health plan will pay us or reimburse you for the procedure. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose health information about you for Hospital operations. These uses and disclosures are necessary to run the Hospital and make sure that patients receive quality care. For example, we may use health information to review treatment and services provided to you. We may also use health information to decide what additional services we should offer and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Hospital personnel for learning purposes. We may disclose health information to contractors or “business associates” that perform various activities important to the operations of our organizations. For example, we may disclose patient information to an external transcription company that transcribes dictation into medical records. Whenever we have an arrangement between the Hospital and a business associate, we will limit the amount of health information we provide to the minimum necessary for the particular task.

Other Types of Uses and Disclosures

We may also use or disclose your health information:

• To contact you as a reminder that you have an appointment for treatment or medical care at the Hospital;
• To tell you about or recommend possible treatment options or alternatives;
• To inform you about health-related benefits and services that may be of interest to you; and
• To contact you as part of our fundraising efforts (unless you object).

Uses and disclosures we may make unless you object. In the following situations, we may disclose your health information if we inform you about the disclosure in advance and you do not object. If you do object, you must tell us in writing that you do not wish to have your health information used in this manner.

• Directory: We may include certain limited information about you in the Hospital directory while you are a patient at the Hospital to assist family, friends and visitors in finding you and learning about your general condition. This information includes your name, location in the Hospital, your general condition (e.g., stable, fair, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name.
  
  
  
• Clergy: Your religious affiliation may be given to a member of the clergy in the Hospital, such as a priest, minister or rabbi, even if he or she doesn’t ask for you by name. This is so the clergy can visit you in the Hospital.
  
  
• Individuals Involved in Your Care: We may use or disclose certain relevant health information about you to family, friends or other persons you designate who are involved in your care or payment related to your health care. We may also use or disclose your information to notify or assist in notifying a family member, personal representative or another person responsible for your care of your location and general condition. We also may disclose health information about you to an authorized entity assisting in a disaster relief effort so that your family can be notified of your location and general condition. Other state and federal law requirements. In situations where New Hampshire laws or other federal laws are more stringent or give patients more rights than federal privacy laws, such laws preempt the federal privacy law and we will abide by the other applicable state or federal law. For example, HIV testing information is subject to greater protections and more limited disclosure under New Hampshire law and information about alcohol and drug abuse treatment is subject to more limited disclosure requirements under another federal law.

Uses and Disclosures Not Requiring Your Authorization

In the following circumstances, we may use or disclose health information without your authorization:

As Required by Law. When required to do so and only to the extent required by law. For example, to report suspected abuse or neglect of an incapacitated adult or a minor. Public Health Activities. To public health or other authorities charged with certain legal obligations, such as preventing or controlling disease, injury or disability or to the FDA regarding FDA regulated products and activities.

Health Oversight Activities. To a health oversight agency for activities authorized by law, including audits, investigations and licensure.

Judicial and Administrative Proceedings. When required by a court or administrative order.

Law Enforcement. To law enforcement officials for certain enforcement purposes, including, for example, the reporting of certain types of wounds or injuries; or pursuant to a warrant, subpoena, or other legal process; for the purpose of identifying or locating a suspect, fugitive, material witness or missing person; reporting a death believed to be a result of criminal conduct, or evidence regarding a crime on the premises.

Coroners, Medical Examiners and Funeral Directors. To coroners, medical examiners or funeral directors in order to identify a deceased person, determine a cause of death or to carry out their duties under the law.

Organ Donations and Transplants. To organ procurement organizations for purposes of organ or tissue donation and transplantation.

Research. Under certain circumstances, for research purposes. All research projects, however, are subject to a special approval process which evaluates a proposed research project and its use of health information, balancing the research needs with patients’ need for privacy of their health information. Before using or disclosing health information for research, the project will have been approved through this research approval process.

Public Safety/Duty to Warn. To warn of a serious threat to a clearly identified or reasonably identifiable person, or a serious threat of substantial damage to real property but only to the threatened person or law enforcement to be able to help prevent the threat.

Military and Veterans. If you are a member of the armed forces, as required by military command authorities, and to foreign military authorities, if you are foreign military personnel.

National Security. To authorized federal officials for specialized government functions such as national security and intelligence.

Workers’ Compensation. As authorized by law in connection with workers’ compensation programs.

Other Uses and Disclosures of Health Information

Other uses and disclosures of health information not covered by this Notice or applicable laws will be made only with your written authorization. If you provide us authorization to use or disclose health information about you, you may revoke this authorization, in writing, at any time, except to the extent that we already have relied on it in making an authorized use or disclosure. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization.

Your Health Information Rights

Although the actual records that we maintain about you belong to us, the health information contained in our records belongs to you. You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy health information about you. We may deny your request to inspect your records in certain very limited circumstances, but you always have a right to a copy of your records. If you request a copy of information, we may charge a fee for the cost of copying, mailing or other costs associated with your request.

Right to Amend. If you feel that health 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 us. We may deny your request for an amendment and if we do, you will be notified of the reason for the denial.

Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures of your health information made after April 14, 2003 for certain purposes other than treatment, payment or health care operations.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operation, or to someone who is involved in your care or the payment for your care, like a family member or friend, and for disaster relief purposes as described in the paragraph above headed “Individuals Involved in Your Care.” 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 or when required by law.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health information and medical matters by alternative means or at alternative locations. For example, you can ask that we only contact you at work or by mail. 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, even if you have agreed to receive a copy in electronic form.

If you wish to exercise any of these rights or you have questions about any of them, please direct your request to:

Privacy Officer
Memorial Hospital
PO Box 5001
North Conway, NH 03860-5001
603-356-5461

Changes to This Notice

We reserve the right to change our privacy practices and the terms of this Notice. We reserve the right to make these changes effective for health information we already have about you as well as any information we receive or create about you in the future. The revised Notice will be available to patients at the Hospital and will be posted in both places and on the Hospital’s website.

Complaints or Questions

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the Secretary of the Department of Health and Human Services. To file a complaint with the Privacy Officer, contact:

Privacy Officer
Memorial Hospital
PO Box 5001
North Conway, NH 03860-5001
603-356-5461

All complaints must be submitted in writing. You will not be penalized or retaliated against in any way for filing a complaint.

If you have any questions about this Notice, please contact the: 

Privacy Officer
Memorial Hospital
PO Box 5001
North Conway, NH 03860-5001
603-356-5461