MACON COUNTY GENERAL HOSPITAL
NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003
Revised Date: May 1, 2004
Revised Date: September 23, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Your rights under the Health Insurance Portability & Accountability Act of 1996 (HIPAA)

PLEASE REVIEW IT CAREFULLY!
Who Will Follow This Notice of Privacy Practices (“Notice”):  
This Notice describes Macon County General Hospital’s (the “Facility”) practices and that of:
•        Any health care professional authorized to enter information in to your medical record  
     maintained by the Facility
•        All departments and units of the Facility
•        Any member of a volunteer group allowed to help you while you are receiving services from the
     Facility
•        All employees, staff, agents and other Facility personnel
•        All entities, sites and locations within this Facility’s system will follow the terms of this Notice.  

They also may share medical information with each other for treatment, payment, and healthcare
operations purposes.

Our Pledge Regarding Medical Information:
We understand that medical information about you and your health is personal and we are committed
to protecting your medical information.  We create a record of care and services you receive at the
hospital  this Facility.  We need this record to provide you with quality care and to comply with certain
legal requirements.  This notice applies to all of the medical records of your care generated by the
Facility, whether made by hospital personnel or your personal doctor.  Your personal doctor may have
different policies or privacy notices regarding the doctor’s use and disclosure of your medical
information created in the doctor’s office or clinic.

This Notice will tell you about the ways in which the Facility may use and disclose medical information
about you.  We also describe your rights and certain obligations we have regarding the use and
disclosure of medical information.

If you have questions about this Notice or the privacy practices at Macon County General Hospital
please contact the Facility Privacy Officer at (615) 666-2147 ext. 348 or P.O. Box 378, Lafayette, TN
37083.

This law requires the Facility to:
1) Make sure that medical information that identifies you is kept private;
2) Inform you of our legal duties and privacy practices with respect to medical information about you;
and
3) Follow the terms of the Notice that is currently in effect.

How The Facility May Use & Disclose Medical Information About You
The following categories describe different ways that the law allows us to use and disclose medical
information.  For each category of uses or disclosures we will explain what we mean and try to give
some examples. Not every use or disclosure in a category will be listed.  However, all of the ways the
Facility is permitted to use and disclose information will fall within one of the categories.

For Treatment: Your medical information may be used to provide you with medical treatment or
services.   We may disclose medical information about you to doctors, nurses, technicians, medical
students, or other hospital workforce members of the Facility who are involved in taking care of you at
the hospital.  
For example, a doctor treating you for a broken leg may need to know if you have diabetes because
diabetes may slow the healing process.  In addition, the doctor may need to tell the dietician if you
have diabetes so that we can arrange for appropriate meals.  Different departments of the Facility may
also share medical information about you in order to coordinate the different things you need, such as
prescriptions, lab work, and x-rays.  We also may disclose medical information about you to people
outside the hospital who may be involved with your medical care, such as family members, home
health nurses, nursing home personnel or others who provide services that are part of your care.

We may release medical information about you to your primary care physician to continue care for you
when you leave the hospital or for follow-up from an emergency room visit.


For Payment: Your medical information may be used and disclosed so that the treatment and services
received at the Facility may be billed and payment may be collected from you, the insurance company,
and/or a third party.
For example, The health plan or insurance company may need information about the care you
received from the Facility so they can provide payment for the costs of services.  Information may also
be given to someone who helps pay for you care.  Your health plan or insurance company may also
need information about a treatment you are going to receive to obtain prior approval or to determine
whether they will cover the treatment.

There are some services provided in our hospital through contracts with business associates.  For
example: radiology services or certain laboratory tests.  We may disclose your health information to
our business associates whom we have contracted with to perform specific duties and to assist with
billing you or your health plan for services rendered.  To protect your information, we do require the
business associate to sign a contract to appropriately safeguard your information.

For Health Care Operation:.  Your medical information may be used and disclosed for purposes of
furthering day-to-day Facility operations.  These uses and disclosures are necessary to run the
Facility and to monitor the quality of care our patients receive.
For example, Your medical information may be:
1)  Reviewed to evaluate the treatment and services performed by our staff in caring for you.
2)  Combined with that of other Facility patients to decide what additional services the Facility should
 offer, what services are not needed, and whether certain new treatments are effective.  
3)  Disclosed to doctors, nurses, technicians, , and other agents of the Facility for review and learning
 purposes.  
4)  Disclosed to health care students, interns and residents.
5)  Combined with information from other facilities to compare how we are doing and see where we can
 improve the care and services offered.  Information that identifies you in this set of medical
 information may be removed so others may use it to study health care and health care delivery
 without knowing who the specific patients are.
6.  Used to assess you satisfaction without services.
7.  Used for population based activities relating to improving health or reducing health care costs.

Facility Census: We may include certain limited information about you in the Facility directory while you
are a patient at the Facility.  This information may include your name, location in the Facility,
admission date and address.

Clergy Members: While you are a patient in the Facility, information about you may be disclosed to
your specific clergy.  This information may include your name, address, and admission date.

Appointment Reminders, Prescriptions and Follow-up calls: Your medical information may be used to
contact you to remind you of an appointment you have for treatment or medical care at the Facility, to
inform you that a prescription is ready for you to pick up or for follow-up calls. Unless you have
requested we communicate with you in a different way, we may leave a message on you answering
machine/voice mail or with a family member or other person who answers the phone if you are not
home.  We will, however, make every effort to limit the information disclosed in these ways.

Treatment Alternatives: Your medical information may be used to tell you about or recommend
possible treatment options or alternative that may be of interest to you.  

Health-Related Benefits and Services:  Your medical information may be used to tell you about health-
related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment of Your Care:  With your permission, your medical
information may be released to a family member, guardian, or other individuals involved in your care.  
They may also be told about your condition unless you have requested additional restrictions.    In
addition, your medical information may be disclosed to an entity assisting in a disaster relief effort so
that your family can be notified about your condition, status, and location.

Fundraising: We will not use your medical information for fundraising activities without your prior
consent.

Research:  Under certain circumstances, your medical information may be used and disclosed for
research purposes.
For Example, A research project may involving comparing the health and recovery of patients who
received one medication to those who received  another, for the same condition.  All research
projects, however, are subject to a special approval process.  The process evaluates a proposed
research project and its use of medical information, balancing the research needs with the patient’s
need for privacy of their medical information.  Your medical information may be disclosed to people
preparing to conduct a research project.

As Required by Law: Your medical information will be disclosed when required to do so by federal,
state, or local authorities, laws, rules and/or regulations.
1)  Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, you medical information will be
 disclosed in response to a court or administrative order, subpoena, discovery request, or other
 lawful process by someone else involved in the dispute when we are legally required to respond.
2)  Law Enforcement:  Your medical information will be released if requested by a law enforcement
 official:
•        In response to a court order, subpoena, 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 obtained the
     person’s agreement;
•        About a death we believe may be the result of criminal conduct; 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.
3) National Security and Intelligence Activities:  Your medical information will be released to authorized
federal officials for intelligence, counterintelligence, and other national security activities authorized
by law.  
4) Protective Services for the President of the United States and Other:  Your medical information may
be disclosed to authorized federal officials so they may provide protection to the President, other   
authorized persons or foreign heads of state or conduct special investigations.
5) To Alert a Serious Threat to Health or Safety:  Your medical information may be used and disclosed
when necessary to prevent a serious threat to your health and safety and that of the public or
another person.  Any disclosure, however, would only be to someone able to help prevent the
threat.
6.  Health Oversight Activities:  Your medical information may be disclosed to a health oversight facility
 for activities authorized by law.  These oversight activities include, for example, audits,
 investigations, inspections, and licensure.  These activities are necessary for the government to
 monitor the health care system, government programs and compliance with civil rights laws.

Private Accreditation Organizations:   Your medical information may be used to fulfill this Facility’s
requirements to meet the guidelines of private facility accreditation organizations such as DNV, Joint
Commission, National Committee for Quality Assurance, etc.

Business Associates:  There are some services provided in this Facility through contracts with
business associates.  Examples include information technology support services or a contracted
radiology service.  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 payer for services rendered.  To protect your health information, however, business
associates, and subcontractors of business associates, are required by federal law to appropriately
safeguard your information.

Directory:  We may include certain limited information about you in the Facility Directory while you are
a patient at the Facility.  The information may include your name, location in the facility, your general
condition (e.g., good, fair) and your religious affiliation.  This information may be provided to members
of the clergy and, except for religious affiliation, to other people who ask for you by name.  You will be
given an opportunity to decline or “opt out:” being listed in the directory at the time of your admission
to the hospital and you may request to have your name taken out of the directory at any time during
your stay.

Future Communications:  We may communicate to you via mail outs, newsletters, or other means
regarding health related information, disease-management programs, wellness programs, or other
community based initiatives or activities our Facility is participating in.

Special Situations
Organ and Tissue Donation: If you are an organ or tissue donor, we may release your medical
information to organizations that handle organ procurement or organ, eye, or tissue transplantation or
to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Medical Devices:  Your social security number and other required information will be released in
accordance with federal laws and regulations to the manufacturer of any medical device(s) you have
implanted or explanted during a hospitalization and to the Food and Drug Administration, if applicable.  
This information may be used to locate you should there be a need with regard to such medical
devices(s).

HIV, Substance Abuse, Mental Health and Genetic Information:
Special privacy protections apply to HIV-related information, alcohol and substance abuse, mental
health, and genetic information.  Some parts of the Notice may not apply to these kinds of protected
health information.  Please check with our Facility Privacy Officer for information about the special
protections that do apply.  For example, if we give you a test to determine if you have been exposed to
HIV, we will not disclose the fact that you have taken the test to anyone without your written consent
unless otherwise required by law.

Military and Veteran: If you are a member of the Armed Forces, we may release medical information
about you as required by military command authorities. If you are a member of the foreign military
personnel, you medical information may be release to the appropriate foreign military authority.   

Workers Compensation: If you seek treatment for a work-related illness or injury, we must provide full
information in accordant with state-specific laws regarding workers’ compensation claims.  Once state-
specific requirements are met and appropriate written request is received, only the records pertaining
to the work-related illness or injury may be disclosed.  

Public Health Risk: Your medical information may be used and disclosed for public health activities.  
These activities generally include the following:
1.   To prevent or control disease, injury, or disability;
2.   To report births and deaths;
3.   To report child abuse or neglect;
4.   To report reactions to medications or problems with products;
5.   To notify people of recalls of products they may be using;
6.   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;
7.   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.

Coroners, Medical Examiners, and Funeral Directors:  We may release medical information to a
coroner or medial examiner.  This may be necessary, for example, to identify a deceased person or
determine the cause of death.  We may also release medical information about patients of the hospital
to funeral directors as necessary to carry out their duties.

Inmate: If you are an inmate of a correctional institution or in the custody of a law enforcement official,
we may release medical information about you to the correctional institution, the institution’s medical
practitioner, or law enforcement official.  This release would be necessary for the following reasons:
1.  For the institution to provide you with health care;
2.  To protect the health and safety of you and others; and
3.  For the safety and security of the correctional institution.

Marketing:   We may post cards and comments received on public display or in advertisements.  We
will not use your health information for marketing communications without your written authorization.

ADDITIONAL SITUATIONS:

Other Uses of Medical Information: Most uses and disclosures of psychotherapy notes, uses and
disclosures of you protected health information for marking purposes and disclosures that constitute a
sale of your protected health information require your authorization prior to such use and disclosure.  
Other uses and disclosures of medical information not covered by the Notice of the laws that apply to
this Facility will be made only with your written authorization.  You understand that we are unable to
take back and disclosures already made with your permission, and that we are required to retain our
records of the care that the Facility provided to you, therefore disclosures that we made in reliance on
your authorization before you revoke it will not be affected by the revocation.  

ADDITIONAL INFORMATION CONCERNING THIS NOTICE:

Changes to This Notice:  We reserve the right to change this Notice and 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.  The Facility will post a current copy of the Notice with the effective date within
the Facility as well as on its website.  In addition, each time you are admitted to the Facility for
care/services, as an inpatient or outpatient, we will offer you a copy of the current Notice in effect.

Complaints:  You will not be penalized for filing a complaint.  If you believe your privacy rights have
been violated, you may file a complaint with the Facility or with the Secretary of the Department of
Health and Human Services.  To file a complaint with the Facility, contact the Facility Privacy Officer
and/or follow the process outlines in this Facility’s Patient Rights documentation.  All complaints must
be submitted in writing.  

Your Rights Regarding Medical Information About You
You have the following rights regarding medical information the Facility maintains about you:

NOTE:  All requests to Inspect and Copy Medical Information or to Receive and Electronic Copy of the
Medical Information that May be Used to Make Decisions About Your Must Be Submitted in Writing to
the Facility Medical Records Department.

Right to Inspect and Copy: You have the right to inspect and copy medical information that is
maintained by this Facility and that is used to make decisions about your care.  You also have the
right to request and explanation or summary of your medical information.  If your request is approved,
we have thirty (30) days in which to respond to your request.  If we are unable to respond within thirty
(30) days (for example, the records you have requested are stored off site), we may request an
additional thirty (30) days in which to respond to your request. You will receive written notice of the
extension if needed and such notice will explain the reasons for the delay and the expected date of
delivery.  We will respond to the request within a reasonable amount of time but not later than sixty
(60) days from the date your written request is submitted to the Medical Records Department.

If you request a paper copy of the information, we may charge a fee for the cost of copying, mailing or
other supplies associated with your request.  

If the Facility uses or maintains an electronic health record in one or more designated record sets with
respect to your medical information, we must provide you with access to the electronic information in
electronic format and the format requested, if it is readily producible, or, if not, in a readable form and
format mutually agreed upon.  You may direct the Facility to transmit the copy to another entity or
person that you designate provided the choice is clear, conspicuous, and specific.  Your request must
be submitted to the Facility Medical Records Department in writing; it must be signed by you; and it
must clearly identify the designated person or persons and where to send the copy.

We may deny your request to inspect and copy in some limited circumstances (see below).  If you are
denied access to medical information, you may request that the denial be reviewed.  Another licensed
health care professional, other than the person who denied your request, will be chosen by the Facility
to review your request and the denial.  The Facility will comply with the outcome of the review.
1.  A licensed health care professional has determined, in the exercise of professional judgement, that
 the access requested is reasonably likely to endanger the life or physical safety of the individual or
 another person.  
2.  The protected health information makes reference to another person (unless such other person is
  a health care provider) and a licensed health care professional has determined, in the exercise of
  professional judgment, that the access requested is reasonably likely to cause substantial harm to
  such other person.  
3.  The request for access is made by the individual’s personal representative, a licensed health care
  professional has determined, in the exercise of professional judgement, that the provision of
  access to such personal representative is reasonably likely to cause substantial harm to the
  individual or another person.  
4.  The information requested is not maintained by our Facility.  In such situation, if we know the
  location of the information requested, we must provide that information to you.  

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 the Privacy Officer.  In addition, you must provide a reason that supports your
request. Your request may be denied if:

1.  Your request is not in writing or does not include a reason to support the request;
2.  The medical information was not created by us, unless the person or entity that created the
 information is no longer available to make the amendment;
3.  The medical information is not part of the medical information kept by or for the facility;
4.  The medical information is not part of the information you would be permitted to inspect and copy;
or
5.  The medical information 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 for purposes other than treatment,
payment and health care operations.

To request this list of accounting of disclosures:

1.  You must submit your request in writing to the Privacy Officer.
2.  Your request must state a time period, which may not be longer than six years and may not include
 dates before April 14, 2003.
3.  Your request should indicate in what form you want the list (for example, on paper, electronically).

The first list you request within a 12-month period will be free.  For additional lists, we may charge you
for the costs of providing the list.  We will notify you of the cost involved and you may choose 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 or the payment for your care, such as a family member or friend. This restriction
does not apply to uses or disclosures of your health information related to your treatment.

To request restrictions, you must make your request in writing to the Facility Privacy Officer.  In your
request, you must tell us:

1.  What information you want to limit;
2.  Whether you want to limit our use, disclosure or both;
3.  To whom you want the limits to apply (for example, disclosure to your spouse).

You also have a right to request that a health care item or service not be disclosed to your health plan
for payment purposes or health care operations.  We are required to honor your request IF the health
care item or service is paid out of pocket and in full.  Your restriction will only apply to records that
elate solely to the service for which you have paid in full.  We are not required to agree to any other
request, and will notify you if we are unable to agree.  If we agree to your request, we must follow your
restrictions (unless the information is necessary for emergency treatment).  You may cancel the
restrictions at any time.  In addition, we may cancel a restriction at any time, unless it relates to a
health care item or service that is paid out of pocket and in full, as long as we notify you of the
cancellation and continue to apply the restriction to information collected before the cancellation.


Right to Confidential Communication: You have the right to request that we communicate with you
about medical matters in a certain way or at a certain location.  For example, you can ask that we only
contact you at work or by mail; or if you wish appointment reminders not to be left on your answering
machine.

To request confidential communications, you must make your request in writing to the Facility Privacy
Officer.  We will not ask you the reason for your 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 the right to a paper copy of this Notice.  You may ask
us to give you a copy of this notice at any time.  Even if you have agreed to receive this Notice
electronically, you are still entitled to a paper copy of this Notice. You may obtain a paper copy of this
notice upon request from the Admitting/ER Registration Office or the Outpatient Registration Office.

Right to Receive Notice of a Breach:  We are required to notify you by first class mail or by email (if
you have indicated a preference to receive information by email), of any breach of your unsecured
protected health information.