WHO WILL FOLLOW THIS NOTICE

This notice describes Ballinger Memorial Hospital District.

OUR DUTIES

We are required by law to:

OUR RIGHTS

We may use your Protected Health Information (PHI) in the following ways without your consent and authorization:

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Consent refers to how we can use your information.

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Authorization refers to when we pass your information along to others.

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FOR YOUR TREATMENT:

Without your consent or authorization, we will use PHI about you to treat you. We will try to get a written consent from you if we can, but in emergencies or when we can’t reasonably get a signed consent from you we may use your information without it. We will pass PHI along to other medical personnel involved in your care, including doctors and nurses at treatment facilities to which you may be taken. We may use radio, telephone, fax, written and computer communications to transmit this information as needed for your care. Copies of your patient care records will be given to people at facilities who treat you. We can disclose information about you to your relatives, friends and other individuals who have a need to know about your condition.

FOR PAYMENT:

Without your consent or authorization, we will submit your PHI to insurance companies, to Medicare or Medicaid as appropriate to obtain payment for our services to you. We may use an outside billing company to process our claims for payment. We may use your PHI for determining medical necessity for your treatment, for justifying our treatments of you for payment purposes, and when an insurance company or other payer requests further information about you to determine our rights to payment. We may transmit your PHI to a collection agency hired by us to collect past due accounts.

FOR HEALTH CARE OPERATIONS:

Without your consent or authorization we will use your PHI in Health Care Operations. Health Care Operations means all activities that we use to evaluate our treatment of you, our employees’ performance in treating you and following our policies and procedures, and other processes that we engage in for the purposes of improving patient care. We may use PHI for Health Care Operations involving:

WHEN REQUIRED BY LAW:

Whenever we are required by law to provide your PHI we will transmit your PHI to others without either your consent or authorization. Some examples are:

OTHER USES:

For any other purposes not listed here which may reasonably be required to carry out the treatment, payment, operations and legal disclosure functions that Ballinger Memorial Hospital may deem reasonably necessary or advisable and required or permitted under any applicable laws. We may use your PHI without your express consent or authorization for other unnamed uses if they can be reasonably said to fall within any of the categories listed above.

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WHEN YOUR AUTHORIZATION IS REQUIRED

Other uses or disclosures of your medical information for other purposes or activities, not listed above, will be made only with your written authorization (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 your revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by our written permission. However, we are unable to take back any disclosures we have already made with your permission.

YOUR RIGHTS:

You have the right to: COMPLAIN TO US OR TO THE SECRETARY OF HEALTH AND HUMAN SERVICES OF THE USA IF YOU THINK WE HAVE VIOLATED YOUR RIGHTS.

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If you file a complaint:

LOOK AT AND COPY YOUR PHI:

You can come to our offices during business hours and request to look at and copy your medical information, subject to the exceptions provided by law:

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Exceptions:

RESTRICT OUR USE OF YOUR PHI:

You have the right to require us to restrict our use and disclosure of your PHI with certain exceptions, but we do not have to agree if any of the following exceptions apply:

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Exceptions:

REQUEST CONFIDENTIAL COMMUNICATIONS:

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. To request confidential communications, you must make your request in writing to the Privacy Officer at Ballinger Memorial Hospital. 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.

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AMEND YOUR PHI: If you think your PHI is not correct, you can ask us to amend it and if we agree we must do so within 60 days from your request. HOWEVER WE CAN REFUSE YOUR REQUEST IF:

REQUEST AN ACCOUNTING FOR OUR USE AND DISCLOSURES OF YOUR PHI DURING THE LAST 6 YEARS BEGINNING ON APRIL 14, 2003., THE DATE WHEN HIPAA PRIVACY PROVISIONS TAKE EFFECT:

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However, we will not be required to account for uses and disclosures prior to April 14, 2003. We do not have to account to you for disclosures made in connection with your treatment, for payment, health care operations or disclosures that were required by law. You have the right to one free accounting in any 12-month period. For additional accountings, we may charge a reasonable fee.

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NO RETALIATION:

WE WILL NOT RETALIATE AGAINST YOU IN ANY WAY FOR EXERCISING ANY OF YOUR RIGHTS UNDER HIPAA.

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HOW TO CONTACT US:

The person for you to contact within our organization if you have any questions or complaints and to exercise any rights you have under HIPAA is:

Privacy Officer

Ballinger Memorial Hospital

P.O. Box 617

Ballinger, Texas 76821-0617

325-365-2531

You have a right to obtain a copy of this notice in writing. You may ask any employee of Ballinger Memorial Hospital to give you a copy of this Notice at any time. We will ask you to sign an acknowledgment that you have received this notice. If you cannot do so, we will make reasonable attempt later to obtain your acknowledgment.