Wills Memorial Hospital

NOTICE OF PRIVACY PRACTICES

As required by the Privacy Standards of Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS PRIVACY NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU (AS A PATIENT OF THIS HOSPITAL) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS PRIVACY NOTICE CAREFULLY

IF YOU HAVE QUESTIONS, PLEASE CONTACT THE PERSON LISTED AT THE BOTTOM OF THIS NOTICE

I. OUR COMMITMENT TO YOUR PRIVACY

Wills Memorial Hospital (the Hospital) is committed to maintaining the privacy of your protected health information (PHI). As we provide treatment and services to you, we create records that contain your medical and personal information, referred to as protected health information, or PHI. We need these records to provide you with quality care and to comply with various legal requirements. The terms of this Privacy Notice apply to all records containing your PHI that are created or retained by the Hospital. We are required by federal and state law to maintain the privacy of your PHI maintained in such records. We also are required by law to provide you with this Privacy Notice of our legal duties and the privacy practices that we have established and which we maintain in the Hospital concerning your PHI. We must follow the terms of the Privacy Notice that we have in effect at the time.

This Privacy Notice provides you with the following important information:

How we may use and disclose your PHI.
Your privacy rights with respect to your PHI.
Our obligations concerning the use and disclosure of your PHI.
Important contact information.

II. CHANGES TO THIS PRIVACY NOTICE

We reserve the right to revise or amend this Privacy Notice. Any revision or amendment to this Privacy Notice will be effective for all of your records that the Hospital has created or maintained in the past, and for any of your records that we may create or maintain in the future. We will post a copy of our current Notice in the Hospital in a visible location at all times. (You may request a copy of our most current Notice at any time. You will be provided with a copy of this Notice upon your admission to the Hospital.)

III. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS

The following categories describe and give some examples of the different ways in which

we may use and disclose your PHI. Not every use or disclosure in a category will be

listed. However, all of the ways we are permitted to use and disclosed PHI will fall

within one of the categories listed below.

1. Treatment. We may use your PHI to provide the inpatient hospital services to you. For example, we may provide x-rays or diagnostic tests at the request of your attending physician. Your physician may use the results to reach a diagnosis, in which case the Hospital would use the test results to provide necessary services to treat your injury or illness.

2. Payment. We may use and disclose your PHI in order to bill and collect payment from you, Medicare, or Medicaid, an insurance company, or other designated third party payor, for the treatment and services we provide to you. For example, we may contact your health plan to certify that you are eligible for benefits, and we may provide your plan with details regarding your treatment to determine if the plan will cover, or pay for your treatment.

3. Healthcare Operations. We may use and disclose your PHI to operate our business. For example, the Hospital may use your PHI top conduct quality assessment and improvement activities, review the performance of physicians on our Medical Staff or of healthcare professionals employed by the Hospital, or for general management or business planning for the hospital.

4. Appointment Reminders. We may use and disclose your PHI to contact you and remind you of an appointment for a scheduled outpatient procedure.

5. Release of Information. The disclosure of PHI may be limited upon your request. As stated in Section V below, you have the right to request restrictions on who receives your medical information. Therefore, if there are specific family members or other persons to whom you do not want your PHI disclosed, please let us know in the manner required by Section V.

6. Health-Related Benefits and Services. We may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

7. Release of Information. The disclosure of PHI may be limited upon your request. As stated in Section V below, you have the right to request restrictions on who receives your medical information. Therefore, if there are specific family members or other persons to whom you do not want your PHI disclosed, please let us know in the manner required by Section V.

8. Fundraising Activities. The Hospital may use your PHI to contact you in an effort to raise money for our organization and its operations. We may disclose your PHI to a foundation related to our organization so that the foundation may contact you in raising money for our organization. In such cases, we would only release contact information such as your name, address and phone number and the dates you received treatment or services at the Hospital. If you do not want us to contact you for such fundraising efforts, you must notify Wills Memorial Hospital PO Box 370, Washington GA 30673 Attn: HIPAA Security Officer.

IV. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe special situations in which the Hospital may use

of disclose your PHI:

1. As Required By Law. The hospital will disclose PHI when required to do so by

federal, state or local law.

2. Public Health Risks. The Hospital will disclose your PHI to public health or

government authorities that are authorized by law to collect information for purposes such as, but not limited to, the following:

1. Maintaining vital records, such as births and deaths

2. Reporting child abuse or neglect

3. Preventing or controlling disease, injury or disability

4. Notifying a person regarding potential risk for spreading or contracting a disease or condition

5. Reporting reactions to drugs or problems with products or devices

6. Notifying individuals if a product or device they may be using has been recalled

7. Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information

8. Notifying your employer under limited circumstances required by law primarily relating to workplace injury or illness or medical surveillance.

3. Health Oversight Activities. The Hospital may disclose your PHI to a public

health oversight agency for oversight activities authorized by law. Oversight

activities can include, for example, investigations, inspections, audits, surveys,

licensure and disciplinary actions, or other activities necessary for the

government to monitor government programs, compliance with civil rights laws

and the healthcare system in general.

4. Lawsuits and Similar Proceedings. The hospital may use and disclose your PHI

in response to a court or administrative order, if you are involved in a lawsuit or

similar proceeding. The hospital also may disclose your PHI in response to a

discovery request, subpoena, or other lawful process by another party involved

in the dispute, but only if the requesting party has made an effort to inform you

of the request or to obtain a qualified protective order protecting the

information the party has requested

5. Law Enforcement. The Hospital may release PHI if asked to do so by

appropriate law enforcement officials as permitted or required under the HIPAA

privacy standards. Some of the circumstances under which the Hospital may

release PHI to law enforcement officials include the following:

1. The hospital provides treatment for certain types of wounds and physical injuries as required by law.

2. The Hospital provides treatment to a person believed to be a crime victim, in certain situations.

3. Where a patient of the Hospital has died, and certain healthcare professionals at the Hospital suspect that the death was caused by criminal conduct.

4. In circumstances where the Hospital reasonably suspects that criminal conduct occurred at the Hospital.

5. In response to a warrant, summons, court order, subpoena or similar legal process.

6. To assist in identifying or locating a suspect, material witness, fugitive or missing person.

7. In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identify or location of the perpetrator).

6. Coroners, Medical Examiners, and Funeral Directors. The hospital may

release PHI to a medical examiner or coroner to identify a deceased individual

or to identify the cause of death. If necessary, we also may release information

in order for funeral directors to perform their services.

7. Organ and Tissue Donation. If you are an organ donor, the Hospital may release

PHI to organizations that handle organ or tissue procurement or transplantation,

including organ donation banks, as necessary to facilitate organ or tissue

foundation and transplantation.

8. Serious Threats to Health or Safety. The hospital may use and disclose your PHI

when necessary to reduce or prevent a serious treat to your health and safety or

the health and safety of another individual or the public. Under these

circumstances, the Hospital will only make disclosures to a person or

organization able to help prevent the threat.

9. Military. If you are a member (or veteran) of U.S. or foreign military forces, the Hospital may release your PHI as required by the appropriate authorities.

10. National Security. The Hospital may disclose your PHI to federal officials for intelligence and national security activities authorized by law. The Hospital also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

11. Inmates. If you are an inmate of a correctional institution, or under the custody of law enforcement officials, the Hospital may disclose your PHI to such correctional institutions or law enforcement officials. Disclosure for these purposes would be necessary; (a) for the institution to provide healthcare services to you; (b) for the safety and security of the institution and/or (c) to protect your health and safety or the health and safety of other individuals.

12. Workers’ Compensation. The hospital may disclose your PHI for workers’ compensation and similar programs, as required by applicable laws.

V. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI that we maintain about you:

1. Requesting Restrictions. You have the right to request a restriction on the Hospital’s use or disclosure of your PHI for treatment, payment or healthcare operations. Additionally, you have the right to request that the Hospital restrict its disclosure of your PHI to only certain individuals involved in your care or the payment for your care. Such as family members and friends. Note that the Hospital is not required to agree to your request. When the Hospital does agree, the Hospital is bound by its agreement, except when otherwise required or permitted by law, or when the restricted information is necessary to treat you in an emergency. In order to request a restriction on our use or disclosure of your PHI, you must make your request to Wills Memorial Hospital PO Box 370, Washington GA 30673, Attn: HIPAA Security Officer, in accordance with the Hospital’s policies. Your request must be in writing and must describe in a clear and concise fashion:

a) The information you wish restricted and how you want it restricted

b) Whether you are requesting to limit the Hospital’s use of your PHI, the Hospital’s disclosure of your PHI or both; and

c) To whom you want the limits to apply.

1. Confidential Communications. You have the right to request that the Hospital communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work, or by mail, rather than by telephone. We will accommodate reasonable requests, but we are not required to accommodate all requests. In order to request a type of confidential communication, you must make a written request to Wills Memorial Hospital PO Box 370, Washington GA 30673 Attn: HIPAA Security Officer specifying the requested method of contact, or the location where you wish to be contacted. You do not need to give a reason for your request.

2. Access and Copies. You have the right to inspect and obtain a copy of the PHI that we maintain about you, including patient medical records and billing records. Note, however, that you do not have the right to inspect or obtain a copy of psychotherapy notes maintained by the Hospital, or of certain other information that may be restricted by law or pursuant to a legal or administrative process or proceeding. You must submit your request in writing to the same address that appears in #2 above, in order to inspect and/or obtain a copy of your PHI. The Hospital may charge a fee for the costs of copying, mailing, labor and supplies associated with your request in accordance with Georgia law. Please contact the person named above for information about such fees.

The Hospital may deny your request to inspect and/or copy some or all of your PHI in certain limited circumstances; however, you may request a review of our denial. A licensed healthcare professional, who was not involved in the denial, will be chosen by the Hospital to conduct reviews of denials. The Hospital will comply with the outcome of the review.

3. Right to Amend. If you feel that PHI that the Hospital maintains about you is incorrect or incomplete, you may ask the Hospital 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 Wills Memorial Hospital, PO Box 370, Washington, GA, 30673, Attn: HIPAA Security Officer. In addition, you must provide a reason that supports your request for the amendment.

The Hospital may deny your request for an amendment if it is not in writing or if it does not include a reason to support the request. In addition, the Hospital may deny your request if you request an amendment to information that:

1. Was not created by the Hospital, unless the person or entity that created the information is no longer available to make the amendment;

2. Is not part of the medical information kept by or for the Hospital;

3. Is not part of the information you would be permitted to inspect and copy, or

4. Is accurate and complete.

4. Accounting of Disclosures. You have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures that the Hospital has made of your PHI for non-treatment or operations purposes. The Hospital is not required to provide you with an accounting of the following disclosures:

1. Disclosures for treatment, payment or the healthcare operations of the Hospital;

2. Disclosures to you;

3. Disclosures incident to uses or disclosures of your information for permitted purposes.

4. Disclosures that you have authorized us to make;

5. Disclosures from the Hospital’s directory to others involved in your care; or for notifying your family member or personal representative about your general condition, location, or death when you have had the opportunity to agree to such disclosures (or they were otherwise permitted);

6. Disclosures for national security or law enforcement;

7. Disclosures that were part of a “limited Data Set” (which is a set of information containing only limited amounts of identifiable information, as permitted by the HIPAA Privacy Rules); or

8. Disclosures that occurred prior to April `14, 2003.

In order to obtain an accounting of disclosures, you must submit your request in writing to Wills Memorial Hospital, PO Box 370, Washington, GA, 30673 Attn: HIPAA Security Officer. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but the Hospital may charge you for additional lists within the same 12-month period. The Hospital will notify you of the costs involved with additional requests, and you may withdraw or modify your request before you incur any costs.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time.

7. Right to File a Complaint. If you believe that your privacy rights have been violated by the Hospital or by an employee of the Hospital, you may file a complaint with the Hospital or with the Secretary of the Department of Health and Human Services. Because we are always interested in improving the quality of services provided to you, we would encourage you to contact the Hospital first. Any complaint should be made in writing to Wills Memorial Hospital, PO Box 370, Washington, GA 30673, Attn: HIPAA Security Officer. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted or required by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Attn: HIPAA Security Officer

Wills Memorial Hospital

PO Box 370

Washington, Georgia 30673

HIPAA PRIVACY RULE:
The HIPAA Privacy Rule requires covered entities to safeguard certain Protected Health Information (PHI) related to a person's healthcare. Information being faxed to you may include PHI after appropriate authorization from the patient or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain PHI in a safe and secure manner. You may not re-disclose without additional patient consent or as required by law. Unauthorized re-disclosure or failure to safeguard PHI could subject you to penalties described in federal (HIPAA) and state law. If you, the reader of this message, are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, please notify us immediately at 7066789212 and destroy the related message.