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!
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. We
need this record to provide you with quality care and to comply with certain legal requirements. This notice
applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your
personal doctor. Your personal doctor may have different policies or notices regarding the doctor=s use and
disclosure of your medical information created in the doctors office or clinic.
This notice will tell you about the ways in which we 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 Privacy Officer at (615) 666-2147 ext. 348 or P.O. Box 378, Lafayette, TN 37083.
We are required by law to: 1) Make sure that medical information that identifies you is kept private; 2) Give you
this notice 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 We 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 we are permitted to use and
disclose information will fall within one of the categories.
˜ For Treatment: We may use medical information about you to determine the best treatment options for you
during the course of your visit to the hospital. We may disclose medical information about you to doctors,
nurses, technicians, medical students, or other hospital personnel 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 dietitian if you have diabetes
so that we can arrange for appropriate meals. Different departments of the hospital 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.
˜ For Payment: We may use and disclose medical information about you so that the treatment and services you
receive at the hospital may be billed for and collected from you, an insurance company, or a third party. For
example, we may need to give your health plan information about surgery you received at the hospital so your
health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you
are going to receive to obtain prior approval or to determine whether your plan 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: We may use and disclose medical information about you for hospital operations.
These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality
care. For example, we may use medical information to review our treatment and services and to evaluate the
performance of our staff in caring for you. We may also combine medical information about many hospital
patients to decide what additional services the hospital should offer, or what services are needed and not
needed. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital
personnel for review and learning purposes. We may remove information that identifies you from this set of
medical information so others may use it to study health care and health care delivery without learning who the
specific patients are.
˜ Hospital Directory: We may include certain limited information about you in the hospital directory while you are
a patient at the hospital. This information may include your name, location in the hospital, your general condition
(e.g. fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation,
may also be released to people who ask for you by name. Your religious affiliation may be given to a member of
the clergy, such as a preacher or priest, even if they don=t ask for you by name. This is so your family, friends,
and clergy can visit you in the hospital and generally know how you are doing. You will be given an opportunity
to decline to be listed in the hospital 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.
˜ Individuals Involved in Your Care or Payment of Your Care: We may release medical information about you to
a family member or friend who is involved in your medical care. We may also give information to someone who
helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital.
In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that
your family can be notified about your condition, status, and location.
˜ As Required by Law: We will disclose medical information about you when required to do so by federal, state,
or local law.
˜ Primary Care Physician: 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.
˜ Notification and Communication with Family: Unless you notify us that you object, we may use or disclose
information to notify or assist in notifying a family member or personal representative responsible for your care,
your location, general condition, or in the event of your death. 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.
˜ Organ and Tissue Donation: If you are an organ donor, we may release 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.
˜ 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. We may also release medical information about foreign military
personnel to the appropriate foreign military authority. We may also disclose medical information about you to
the Department of Veterans Affairs upon your separation or discharge from military services. This disclosure is
necessary for the Department of Veterans Affairs to determine if you are eligible for certain benefits. We may
use and disclose to components of the Department of Veterans Affairs medical information about you to
determine whether you are eligible for certain benefits.
˜ Workers Compensation: We may release medical information about you for workers= compensation or similar
programs. These programs provide benefits for work-related injuries or illness.
˜ Public Health Risk: We may disclose medical information about you 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 or elder 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 by the law.
˜ 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 about to help prevent the threat.
˜ Health Oversight Activities: We may disclose medical information to a health oversight agency 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.
* Lawsuit and Disputes: If you are involved in a lawsuit or dispute, we may also disclose medical information
about you in a response to a court or administrative order. We may also disclose medical information about you
in response to a subpoena, discover 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
* Law Enforcement: We may release medical information if asked to do so 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 as required by the law;
*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.
*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.
˜ Appointment Reminders and Follow-up calls: We may contact you to provide appointment reminders or for
follow-up calls. You have the right to request to receive communications regarding your personal health
information from us by alternative means. We will accommodate reasonable requests.
˜ 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.
˜ 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 to conduct special investigations.
˜ 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 (1) for the institution to provide you with health care; (2)
to protect your health and safety or the health and safety of others; or (3) for the safety and security of the
˜ Health Related Benefits and Marketing: We may contact you with information about treatment alternatives or
other health-related benefits and services that may be of interest to you. 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.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain 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 your 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 your
or for personal use, you must submit your request in writing to the Privacy Officer. If you request a copy of the
information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access
to medical information, you may request that the denial be reviewed. 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 original 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 the
Privacy Officer. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the
request. In addition, we may deny your request if you ask us to amend information that:
* Was not created by us, unless the person or entity that created the information is no longer available to make
* 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, with the exception of disclosures for treatment,
payment, or hospital operations, directory listings, certain government functions and disclosures which you
yourself requested or signed for.
To request this list of accounting of disclosures, you must submit your request in writing to the Privacy Officer.
Your request must state a time period, which may not be longer than six years and may not include dates before
April 14, 2003. If you request this list more than once within a 12-month period, we may charge you a
reasonable fee for the costs of providing the additional list(s).
˜ 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. For example, you could ask that we 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 the Health Information Department. 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; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
˜ 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 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 copy of this notice at our website, www.mcgh.net . You may obtain a paper copy of this
notice upon request from the Admitting/ER Registration Office or the Outpatient Registration Office.
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 post a copy of the current notice in the hospital. The notice will contain on the first
page, 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.
Complaint: If you believe your privacy rights have been violated, you may file a complaint with the hospital or
with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital
contact the Hospital=s Privacy Officer at Macon County General Hospital, P.O. Box 378, Lafayette, TN
37083. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Medical Information: Other uses or disclosures of medical information not covered by the notice
or the laws that apply to us 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
by 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 the care that we provided to you.
|MACON COUNTY GENERAL HOSPITAL
NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
Revised Date: May 1, 2004