• Any health care professional authorized to enter information into your hospital chart.
• All departments and units of Choctaw Memorial Hospital.
• Any member of a volunteer group we allow to help you while you are in the hospital.
• All employee, staff and other hospital personnel.

• basis for planning your care and treatment
• means of communication among many health professionals who contribute to your care
• legal document describing the care you received
• means by which you or a third-party payer can verify that services billed were actually provided
• tool in education health professionals
• source of data for medical research
• source of information for public health officials charged with improving the health the nation
• source of data for facility planning and marketing
• tool with which we can access and continually work to improve the care we render and the outcomes we achieve

• ensure its accuracy
• better understand who, what, when, where, and why others may access your health information
• make more informed decisions when authorizing disclosure to others

Your Health information Rights

• request a restriction on certain uses and disclosures of your information as provided by 45CFR 164.522
• obtain a paper copy of the notice of information practices upon request
• inspect and obtain a copy of your health record as provided for in 45 CFR 164.524
• amend your health record as provided in 45 CFR 164.528
• obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
• request communications of your health information by alternative means or at alternative locations
• revoke your authorization to use or disclose health information except to the extent that action has already been taken

• maintain the privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice
• notify you if we are unable to agree to a requested restriction
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We reserve the right to change our practices and to make new provisions effective for all protected health information we maintain. Should our information practices change, we will make an attempt to mail a revised notice to the address you’ve supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Director of Health Information Management at 580-317-9530

If you believe your privacy rights have been violated, you can file a complaint with the Director of Health Information Management or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment, and Health Operations

We will use your health information for treatment.

For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.

We will 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 this hospital.

We will use your health information for payment

For Example: A bill may be sent to you or a third-party payor. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, provedures, and supplies used

We will use your health information for regular health operations.

For example: Members of the Medical Staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record (but not your name) to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, and certain laboratory tests. 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 and bill you or your third-party payor for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information

Directory: unless you notify us that you object, we will us that you object, we will use your name, location in the hospital, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Funeral Directors, Coroner and Medical Examiners: We may disclose health information to funeral directors consistent with the applicable law to carry out their duties.

Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation or transplant.

Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund Raising: We may contact you as part of a fund raising effort.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health: as required by law, we may disclose your health information 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 child abuse or neglect; to report reactions to medications or problems with products; 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; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena, court order, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime, if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death we believe may be the result of criminal conduct; about criminal conduct at the hospital; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

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 prevent the threat.

Special Situations

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the g overnment to monitor the health care system, government programs, and compliance with civil rights laws.

National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

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 may disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Protective services for the President and Others: 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 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 medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution tp provide your health care; (2) to protect you health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Your rights regarding medical information about you.

Right to inspect and copy: You have the right to inspect and copy medical information that may be used to make decisions about you care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Health Information Management Department of Choctaw Memorial Hospital. If you request a copy of the information, there will be a fee charges for the costs of copying, mailing or other supplies associated with your request.

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 revisited. 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.

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 Choctaw Memorial Hospital’s Health Information Management Director. In addition, you must provide a reason that supports the request.

• Was not created by us, unless the person or entity that created the information is no longer available to 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
• Is accurate and complete

Right to an Accounting of Disclosures: You have the right to request an “ accounting of disclosures.” This is a list of disclosures we made of medical information about you.

To request this list of accounting disclosures, you must submit your request in writing to Choctaw Memorial Hospital’s Health Information Management Department. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate what form you want the list ( for example, on paper, electronically). The first list you request within ta twelve month period will be free. For additional lists, we will charge you for the costs of providing the list. We will notify you of the cost involved and you may chose to withdraw or modify your request at that time before any costs are incurred.

Right to 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 ot the payment for your care, like a family member or friend. For example, you could ask that we do not use or disclose information about a surgery you had.

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.

To request restrictions, you must make your request in writing to Choctaw Memorial Hospital’s Health Information Department. In your request you must tell us (1) what health information you want to limit; (2) whether you want to limit our use, disclosure or both; and to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Choctaw Memorial Hospital’s Health Information Management Department. We will not ask you the reason for the request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a paper copy of this notice: You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

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 have available the current notice in the hospital. The notice will contain on each page, in the bottom left hand corner, 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.

Other Uses of Medical Information: Other uses and disclosures of medical information not covered by this notice or the laws that apply to use 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 in your written authorization. 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 care that we provided to you.