Windom Area Hospital

Patient Privacy

WINDOM AREA HOSPITAL
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The terms of this Notice of Privacy Practices applies to all
Sanford Health entities, operating as a clinically integrated health care arrangement, as well as the physicians and other licensed professionals seeing and treating patients at each of its facilities. See the Sanford Organized Healthcare Arrangement Entities sheet on the back side for a complete listing of these facilities and their locations.

This Notice describes how we will use and disclose your protected health information. The policies outlined in this Notice apply to all of your health information generated by this Organization, whether recorded in your medical record, invoices, payment forms, videotapes or other ways. Similarly, these policies apply to the protected health information gathered from other Organizations by any healthcare professional, employee or volunteer who participates in your care.USES AND DISCLOSURES OF YOUR HEALTH

INFORMATION1) In some circumstances we are permitted or required to use or disclose your protected health information without obtaining your prior authorization and without offering you the opportunity to object. These circumstances include:
(a) Uses or disclosures for purposes relating to treatment,
payment and health care operations:
i) Treatment. We may use or disclose your protected
health information for the purpose of providing, or
allowing others to provide treatment to you. An
example would be if your primary care physician
discloses your protected health information to another
doctor for the purposes of a consultation.

* Also, we may contact you with appointment
reminders or information about treatment
alternatives or other health-related benefits and
services that may be of interest to you.

ii) Payment. We may use and/or disclose your protected
health information for the purpose of allowing us, as
well as other entities, to secure payment for the health
care services provided to you. For example, we may
inform your health insurance company of your
diagnosis and treatment in order to assist the insurer in
processing our claim for the health care services
provided to you.

iii) Health Care Operations. We may use and/or disclose your protected health information for the purposes of our day-to-day operations and functions. We may also disclose your protected health information to another covered entity, to allow it to perform its day-to-day functions, if we both have a relationship with you. For example, we may compile your protected health information, along with that of other patients, in order to allow a team of our health care professionals to
review that information and make suggestions concerning how to improve the quality of care provided at this facility. We may also disclose protected health information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes.

* In addition, we may contact you as part of our efforts to raise funds for the Organization. All fundraising communications will include information about how you may opt out of future fundraising communications.

(b) To create material(s) that originally had any identifying information concerning you deleted from the final material(s);

(c) To create materials that have most of the identifying information about you deleted from the final materials, to allow other entities to conduct research, public health, |or health care operation activities.

(d) When required by law;

(e) For public health purposes;

(f) To disclose information about victims of abuse, neglect, or domestic violence;

(g) For health oversight activities, such as audits or civil, administrative or criminal investigations;

(h) For judicial or administrative proceedings;

(i) For law enforcement purposes;

(j) To assist coroners, medical examiners or funeral directors with their official duties;

(k) To facilitate organ, eye or tissue donation;

(l) For certain research projects that have been evaluated and approved through a research approval process that takes into account patients’ need for privacy;

(m) To avert a serious threat to health or safety;

(n) For specialized governmental functions, such as military, national security, criminal corrections, or public benefit purposes; and

(o) For workers’ compensation purposes, as permitted by law.

2) We may also use or disclose your protected health information in the following circumstances. However, except in emergency situations, we will inform you of our intended action prior to making any such uses and disclosures and will, at that time, offer you the opportunity to object.

(a) Directories. We may maintain a directory of patients that includes your name and location within the facility, your religious designation, and information about your condition in general terms that will not communicate specific medical information about you. Except for your religion, we may disclose this information to any person who asks for you by name. We may disclose all directory information to members of the clergy.

(b) Notifications. We may disclose to your relatives or close personal friends any protected health information that is directly related to that person’s involvement in the provision of, or payment for, your care. We may also use and disclose your protected health information for the purpose of locating and notifying your relatives or close personal friends of your location, general condition or death, and to Organizations that are involved in those tasks during disaster situations. Except as described above, disclosures of your protected health information will be made only with your written authorization. You may revoke your authorization at any time, in writing, unless we have taken action in reliance upon your prior authorization, or if you signed the authorization as a condition of obtaining insurance coverage.

YOUR RIGHTS

1) To Request Restrictions. You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment or health care operations purposes or notification purposes. We are not required to agree to your request. If we do agree to a restriction, we will abide by that restriction unless you are in need of emergency treatment and the restricted information is needed to provide that emergency treatment. To request a restriction, submit a written request to the Contact listed on the final page of this Notice.

2) To Limit Communications. You have the right to receive confidential communications about your own protected health information by alternative means or at alternative locations. This means that you may, for example, designate that we contact you only via e-mail, or at work rather than home. To request communications via alternative means or at alternative locations, you must submit a written request to the Contact listed on the final page of this Notice. All reasonable requests will be granted.

3) To Access and Copy Health Information. You have the right to inspect and copy any protected health information about you other than psychotherapy notes, information compiled in anticipation of or for use in civil, criminal or administrative
proceedings, or certain information that is governed by the Clinical Laboratory Improvement Act. To arrange for access to your records, or to receive a copy of your records, you should submit a written request to the Contact listed on the last page of this Notice. If you request copies, you will be charged our regular fee for copying and mailing the requested information. Despite your general right to access your protected health information, access may be denied in some limited circumstances.

For example, access may be denied if you are an inmate at a correctional institution or if you are a participant in a research program that is still in progress. Access may be denied if the federal Privacy Act applies. Access to information that was obtained from someone other than a health care provider under a promise of confidentiality can be denied if allowing you access would reasonably be likely to reveal the source of the information. The decision to deny access under these circumstances is final and not subject to review.

In addition, access may be denied if (i) access to the information in question is reasonably likely to endanger the life and physical safety of you or anyone else, (ii) the information makes reference to another person and your access would reasonably be likely to cause harm to that person, or (iii) you are the personal representative of another individual and a licensed health care professional determines that your access to the information would cause substantial harm to the patient or another individual. If access is denied for these reasons, you have the right to have the decision reviewed by a health care professional who did not participate in the original decision. If access is ultimately denied, the reasons for that denial will be provided to you in writing.

4) To Request Amendment. You may request that your protected health information be amended. Your request may be denied if the information in question: was not created by us (unless you show that the original source of the information is no longer available to seek amendment from), is not part of our records is not the type of information that would be available to you for inspection or copying (for example, psychotherapy notes), or is accurate and complete. If your request to amend your protected health information is denied, you may submit a written statement disagreeing with the denial, which we will keep on file and distribute with all future disclosures of the information to which it relates. Requests to amend protected health information must be submitted in writing to the Contact listed on the final page of this Notice.

5) To an Accounting of Disclosures. You have the right to an accounting of any disclosures of your protected health information made during the six-year period preceeding the date
of your request. However, the following disclosures will not be accounted for: (i) disclosures made for the purpose of carrying out treatment, payment or health care operations, (ii) disclosures made to you, (iii) disclosures of information maintained in our patient directory, or disclosures made to persons involved in your care, or for the purpose of notifying your family or friends about your whereabouts, (iv) disclosures for national security or intelligence purposes, (v) disclosures to correctional institutions or law enforcement officials who had you in custody at the time of disclosure, (vi) disclosures that occurred prior to April 14, 2003, (vii) disclosures made pursuant to an authorization signed by you, (viii) disclosures that are part of a limited data set, (ix) disclosures that are incidental to another permissible use or disclosure, or (x) disclosures made to a health oversight agency or law enforcement official, but only if the agency or official asks us not to account to you for such disclosures and only for the limited period of time covered by that request. The accounting will include the date of each disclosure, the name of the entity or person who received the information and that person’s address (if known), and a brief description of the information disclosed and the purpose of the disclosure. To request an Accounting of Disclosures, submit a written request to the Contact listed on the final page of this Notice.

OUR DUTIES

1) We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of our legal duties and privacy practices.

2) We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and to make those changes applicable to all health information that we maintain. Any changes to this Notice will be posted on our website and at our facilities, and will be available from us upon request.

COMPLAINTS

You can complain to us and to the federal Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To lodge a complaint with us, please file a written complaint with the Contact set forth below. This Contact person will also provide you with further information about our privacy policies upon request.

No action will be taken against you for filing a complaint.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE

You will be asked to sign an acknowledgment form that you received this Notice of Privacy Practices.

EFFECTIVE DATE

This Notice of Privacy Practices is effective April 14, 2003

Contact Person

Gerri Burmeister
Windom Area Hospital
PO Box 339
Windom, MN 56101
Phone: 1-507-831-2400

ADDITIONAL NOTICES:
NOTICE OF ORGANIZED HEALTH CARE
ARRANGEMENT FOR HEALTH SYSTEM

The Health System, its component hospitals, the independent contractor members of their Medical Staffs (including your physician), and other related health care providers have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment and health care operations. This enables us to better address your health care needs in a clinically integrated setting. This notice is being provided to you as a supplement to this Notice of Privacy Practices.

NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT BETWEEN HOSPITAL AND MEDICAL STAFF

Each of the Hospitals, the independent contractor members of its Medical Staff (including your physician), and other health are providers affiliated with the Hospitals have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operations. This enables us to better address your health care needs. This notice is being provided to you as a supplement to this Notice of Privacy Practices.

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Sanford Clinic Molecular Imaging, Sioux Falls, SD

Sanford Clinic Mountain Lake, Mountain Lake, MN

Sanford Clinic Nephrology, Sioux Falls, SD

Sanford Clinic Neurology, Sioux Falls, SD

Sanford Clinic Neurosurgery & Spine, Sioux Falls, SD

Sanford Clinic Nuclear Medicine, Sioux Falls, SD

Sanford Clinic Occupational Medicine & Walk-in Clinic, Sioux Falls, SD

Sanford Clinic Ophthalmology/Optometry, Sioux Falls, SD

Sanford Clinic Orthopedics & Sports Medicine, Sioux Falls, SD

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Sanford Clinic Podiatry, Sioux Falls, SD

Sanford Clinic Pulmonary Medicine, Sioux Falls, SD

Sanford Clinic Radiology, Sioux Falls, SD

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Sanford Clinic Rheumatology, Sioux Falls, SD

Sanford Clinic Sports Medicine, Sioux Falls, SD

Sanford Clinic Surgical Associates, Sioux Falls, SD

Sanford Clinic Transplant / Nephrology, Sioux Falls, SD

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Sanford Clinic Urogynecology & Reconstructive Pelvic Surgery, Sioux Falls, SD

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Sanford Home Medical Equipment, Sioux Falls, SD

Sanford Jackson Medical Center, Jackson, MN

Sanford Clinic Jackson, Jackson, MN

Sanford Clinic Lakefield, Lakefield, MN

Sanford Luverne Medical Center, Luverne, MN

Sanford Mid-Dakota Medical Center, Chamberlain, SD

Sanford Clinic Chamberlain, Chamberlain, SD

Sanford Clinic Kennebec, Kennebec, SD

Sanford Clinic Oacoma, Oacoma, SD

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Sanford Sheldon Medical Center, Sheldon, IA

Lake Park Clinic, Lake Park, IA

Sanford Clinic Hartley, Hartley, IA

Sanford Clinic Sanborn, Sanborn, IA

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Sanford Clinic Walnut Grove, Walnut Grove, MN

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Winner Regional Healthcare Center, Winner, SD

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