Ottumwa Regional Health Center

Notice of Privacy Practices

Effective Date of This Notice: 1 March 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.

Ottumwa Regional Health Center is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at Ottumwa Regional please contact:

Privacy Officer

1001 Pennsylvania Ave.

Ottumwa, IA 52501

684-3232

privacyofficer@orhc.com

I. How Ottumwa Regional may Use or Disclose Your Health Information

Ottumwa Regional collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of Ottumwa Regional, but the information in the medical record belongs to you. Ottumwa Regional protects the privacy of your health information. The law permits Ottumwa Regional to use or disclose your health information for the following purposes:

1. Treatment. The types and amounts of patient information provided to other health care providers will be limited to relevant and appropriate information needed to provide you medical care and treatment. For example, we will not release any previous pregnancy information if you are being treated for a sprained ankle

2. Payment. We may disclose your health information to third party payers, such as your insurance company, Medicare or Medicaid in order to receive payment for services rendered.

3. Regular Health Care Operations. We may disclose your health information to monitor or review hospital services such as evaluating the quality of health care services, compliance with hospital rules and regulations, and billing audits. We may also disclose your health information to other health care providers to the extent necessary for them to provide you the appropriate level of medical care and treatment.

4. Information provided to you. We will disclose health information to you in accordance with this notice of privacy practices. We may also contact you by appropriate means to remind you of appointments or provide you with information relating to your treatment.

5. Directory. We may list your name, where you are located in our facilities, your general medical condition and your religious affiliation in our directory. This information may be provided to members of the clergy. This information, except your religious affiliation, may be provided to other people who ask for you by name. If you do not want us to list this information in our directory and provide it to clergy and others, you must tell us that you object at the time of your admission, or any time thereafter.

6. Notification and communication with family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

7. Required by law. We may use and disclose your health information as required by law.

8. Public health. We may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

9. Health oversight activities. We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.

10. Judicial and administrative proceedings. We may disclose your health information in the course of any administrative or judicial proceeding.

11. Law enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.

12. Deceased person information. We may disclose your health information to coroners, medical examiners and funeral directors.

13. Organ donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

14. Research. We may disclose your health information to researchers conducting research that has been approved by an Ottumwa Regional’s Institutional Review Board.

15. Public safety. We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

16. Specialized government functions. We may disclose your health information for military, national security, prisoner and government benefits purposes.

17. Worker’s compensation. We may disclose your health information as necessary to comply with worker’s compensation laws.

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

19. Fund-raising. We may contact you to participate in fund-raising activities.

20. Health plan. We may disclose your health information to the sponsor of your health plan.

21. Change of Ownership. In the event that Ottumwa Regional is sold or merged with another organization, your health information/record will become the property of the new owner.

II. When Ottumwa Regional May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, Ottumwa Regional will not use or disclose your health information without your written authorization. If you do authorize Ottumwa Regional to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. A revocation of authorization will be effective on the date it is received and will not affect previous disclosures.

III. Your Health Information Rights

1. You have the right to request restrictions on certain uses and disclosures of your health information. Ottumwa Regional is not required to agree to the restriction that you requested.

2. You have the right to inspect and copy your health information. You may be charged a nominal fee for requested copies of your medical record.

3. You have a right to request that Ottumwa Regional amend your health information that is incorrect or incomplete. Ottumwa Regional is not required to change your health information and will provide you with information if your request is denied and how you can disagree with the denial.

4. You have a right to receive an accounting of disclosures of your health information made by Ottumwa Regional except that Ottumwa Regional does not have to account for the disclosures described in parts 1 (treatment), 2 (payment), 3 (health care operations), 4 (information provided to you), 5 (directory listings) and 16 (certain government functions) of section I of this Notice of Privacy Practices.

5. You have the right to request confidential communication of protected health information.

6. You have a right to a paper copy of this Notice of Privacy Practices.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact

Privacy Officer

1001 Pennsylvania Ave.

Ottumwa, IA 52501

684-3232

privacyofficer@orhc.com

IV. Changes to this Notice of Privacy Practices

Ottumwa Regional reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, Ottumwa Regional is required by law to comply with this Notice. In the event that changes are made to this Notice, the changes will be posted on the Hospital ‘s web site www.orhc.com and you will be provided with a written copy at your next treatment contact with Ottumwa Regional. You may also request a copy of the Privacy Policy at any time.

V. Complaints

Complaints about this Notice of Privacy Practices or how Ottumwa Regional handles your health information should be directed to:

Privacy Officer

1001 Pennsylvania Ave.

Ottumwa, IA 52501

684-3232

privacyofficer@orhc.com

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services

Office of Civil Rights

Hubert H. Humphrey Bldg.

200 Independence Avenue, S.W.

Room 509F HHH Building

Washington, DC 20201

You may also address your complaint to one of the regional Offices for Civil Rights. A list of these offices can be found online at http://www.hhs.gov/ocr/regmail.html.

The filing of a complaint is protected by law and Ottumwa Regional will not retaliate against any person for filing a complaint.

The Notice of Privacy Practices set out above has been adopted as part of an Organized Health Care Arrangement (OHCA) provided by law. The OHCA exists for the purpose of providing a joint Notice of Privacy Practices for hospital purposes. Individual members of the OHCA are not responsible for the professional acts of other members nor are they responsible for the compliance efforts of other members with respect to privacy of health information. You may still receive a separate Notice of Privacy Practices for office based services from your Physician. This Notice of Privacy Practices is effective at Ottumwa Regional Health Center, clinics operated by Ottumwa Regional Health Center and the individual offices of the Physician members of the OHCA.

The members of the OHCA are:

Dr. Ayesha Ahmad	Dr. Eric Cheung	Dr. Marc Hines	Dr. Peter Reiter
Dr. Jashim Ahmed	Dr. Arun Chowla	Dr. Norman Hutchinson	Dr. Layth Saymeh
Dr. Baha Al-Shawwa	Dr. Maha Dawood	Dr. Scott King	Dr. Paul Scott
Dr. Richard Ameln	Dr. Q. Stokes Dickins	Dr. Dale Lensing	Dr. Rohit Seem
Dr. Kurt Anderson	Dr. Steven Ellison	Dr. Navreet Malhi-Chowla	Dr. Dipak Shah
Dr. Akhtar Ashraf	Dr. Donalee Foster	Dr. Elvin McCarl	Dr. Greg Thorgaard
Dr. Hazel Ashraf	Dr. Prashant Gajwani	Dr. John McKeown	Dr. Joyce Vista-Wayne
Dr. Ajay Bhargava	Dr. Jerome Gleich	Dr. William McMillin	Dr. Kent Walker
Dr. J. Lynn Birchmier	Dr. Mary Graeff	Dr. Debra Miller	Dr. Anil Warrier
Dr. Jeffrey Bittner	Dr. Ron Graeff	Dr. Mariannette Miller-Meeks	Dr. Kenneth Wayne
Dr. Stanley Blew	Dr. Ted Haas	Dr. John O’Brien	Dr. David Wetrich
Dr. Robert Blommer	Dr. Adnan Hashmi	Dr. Nancy O’Brien
Dr. Brandon Bourgeous	Dr. Jay Heitsman	Dr. Tamas Otrok
Dr. Donald Buddecke		Dr. Michael Pogel
Dr. Darwyn Chern		Dr. Raghu Pulla Reddy

The undersigned acknowledges receipt of the Notice of Privacy Practices.

Signature __________________________________________________ Date _____________________

Patient Name _____________________________________

Medical Record Number ____________________________