Notice of Privacy Practices HENDRICKS COMMUNITY HOSPITAL ASSOCIATION NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. Hendricks Community Hospital Association is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. Hendricks Community Hospital Association is required by law to abide by the terms of this Notice, and we reserve the right to change the terms of this notice, making any revision applicable to all the protected health information we maintain. If Hendricks Community Hospital Association revises the terms of this Notice, it will post a revised notice at the Hospital and will make paper copies of this Notice of Privacy Practices for Protected Health Information available upon request. HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED Hendricks Community Hospital Association will use your medical information as part of rendering patient care. For example, your medical information may be used by the health care professional treating you, by the business office to process your payment for the services rendered and by administrative personnel reviewing the quality and appropriateness of the care you receive. Hendricks Community Hospital Association may also use and/or disclose your information in accordance with federal and state laws for the following purposes: Hendricks Community Hospital Association 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. Hendricks Community Hospital Association may contact you to raise funds for the Hospital. Hendricks Community Hospital Association may disclose medical information when required by the United States Department of Health and Human Services as part of an investigation or determination of the Hospital’s compliance with relevant laws. Unless you object, and with the exception of Behavior Health Patients, Hendricks Community Hospital Association will include general information, including your name, location in the hospital, your condition described in general terms and your religious affiliation in a directory of individuals located in the Hospital. The directory information, except for your religious affiliation, will be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, even if they do not ask for you by name. Unless you object, and with the exception of Behavior Health Patients, Hendricks Community Hospital Association may disclose to family members, other relatives or those personal friends the medical information directly relevant to such person’s involvement with your care. Unless you object, and with the exception of Behavior Health Patients, Hendricks Community Hospital Association may use or disclose your medical information to notify a family member, a personal representative or other person responsible for your care of your location, general condition, or death. Hendricks Community Hospital Association may disclose your medical information to a public or private entity for the purpose of coordinating with that entity to assist in disaster relief efforts. Hendricks Community Hospital Association may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention. Hendricks Community Hospital Association may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure of disciplinary actions, administrative and/or legal proceedings. Hendricks Community Hospital Association may disclose your medical information in the course of certain judicial or administrative proceedings. Hendricks Community Hospital Association may disclose your medical information for law enforcement purposes or other specialized government functions. Hendricks Community Hospital Association may use or disclose your medical information to an organ donation and procurement organization. Hendricks Community Hospital Association may use or disclose your information for certain research purposes. Hendricks Community Hospital Association may use or disclose your medication information to prevent or lessen a serious threat to the health or safety of another person or the public. Hendricks Community Hospital Association may disclose your information as authorized by laws relating to workers’ compensation or similar programs. Hendricks Community Hospital Association will not use or disclose your medical information for any other purpose without your written authorization. Once given, you may revoke your authorization in writing at any time. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION You have the following rights with respect to your medical information: The right to request restrictions on certain uses and disclosures of your medical information. Hendricks Community Hospital Association is not required to agree to your requested restriction The right to receive communications from Hendricks Community Hospital Association in a confidential manner. The right to inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records. The right to request an amendment of your medical information. Hendricks Community Hospital Association may deny your request for certain specific reasons, and, if denied, the Hospital will provide you with a written explanation for the denial and information regarding further rights you would have at that point. The right to receive an accounting of the disclosures of your medical information made by Hendricks Community Hospital Association in the six years prior to your request, except for disclosures for treatment, payment or Hospital operational purposes, and for certain other specific disclosure types. The right to request a paper copy of this Notice of Privacy for Protected Health Information. The right to complain to Hendricks Community Hospital Association and/or to the United States Department of Health and Human Services if you believe that the Hospital has violated your privacy rights. To complain to Hendricks Community Hospital Association, please contact the Hospital’s Privacy Officer at 507-275-3134 or by writing to 503 East Lincoln Street, Hendricks, Minnesota 56136. If you choose to file a complaint, you will not be retaliated against in any way. If you would like further information regarding your rights or regarding the uses and disclosures of your medical information, you may contact Hendricks Community Hospital Association’s Corporate Compliance Officer at 507-275-3134 or by writing to 503 East Lincoln Street, Hendricks, Minnesota 56136. THIS NOTICE IS EFFECTIVE APRIL 14, 2003.