Patient’s Right to Privacy
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. This notice explains our privacy practices and your rights regarding
your medical information. If you have any questions or further information
about this notice, you can contact a hospital representative at 740-435-CARE
(2273) or by email at email@example.com.
Our Pledge to Protect Your Medical Information:
Southeastern Med recognizes that your medical information
is personal and we are committed to protecting your privacy. We record the care
and treatment you receive in a medical record and, so that we can best meet your
medical needs, we share your medical record with all the providers involved in your
care. We share your information only to the extent necessary to conduct our business
operations, to collect payment for the services we provide you and to comply with
the laws that govern health care. We will not use or disclose your information for any
other purpose without your permission. We are required by law to: Make sure that
medical information that identifies you is kept private; Give you this Notice of our
legal duties and Privacy Practices with respect to medical information about you;
Follow the terms of the Notice that is currently in effect.
Who Will Follow This Notice
The following parties share Southeastern Med’s
commitment to protect your privacy and will comply with this Notice: All
authorized health care professionals, associates, volunteers, trainees, students,
contractors and medical staff. All entities, sites and locations of Guernsey Health
Systems and Southeastern Med that provide health
care to the public including, but not limited to: United Ambulance, Superior Med,
LLC., and Cambridge Regional Cancer Center. In addition, these entities, sites and
locations may share medical information with each other for treatment, payment
or health care operations described in this notice.
How We May Use And Disclose Your Medical Information
We use and disclose medical information in many ways. For each category of uses
or disclosures we will explain what we mean and give 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 the categories.
We may use your medical information to provide you with medical treatment or
services. We may disclose your medical information to doctors, nurses, technicians,
nursing and medical students or hospital associates who are involved in your care.
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. The doctor may also
need to tell the dietitian if you have diabetes so that we can arrange for nutritional
counseling. We also may share your medical information in order to coordinate
different things you need such as prescriptions, lab work and diagnostic testing
as well as to people who may be involved in your medical care such as family
members, clergy, rehabilitation centers and other health care providers.
In addition, unless you opt out, any authorized health care provider who agrees to
participate with Health Information Exchanges (HIEs) may also electronically access
and use your protected health information to provide treatment to you. If you opt
out, your protected health information will not be shared electronically through the
HIE network; however, it will not impact how your information is otherwise typically
accessed, used and released in accordance with this Notice and the law.
We may use and disclose your medical information so that the treatment and
services you received may be billed for and payment may be collected from you
or on your behalf from an insurance company or a third party. For example, we
may need to give your health plan information about surgery you received 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. We may also disclose
your medical information to other health care providers who have provided
services to you when necessary for them to obtain payment on your behalf.
Use and disclosure of your medical information for healthcare operations is
necessary to run the business and ensure that all patients receive quality care.
For example, we may use your medical information to review our treatment and
services and to evaluate the performance of our staff in caring for you. We may
also combine your medical information with medical information about other
patients to decide what additional services should be offered, what services are
not needed, whether treatments are effective and to compare our performance
to see where we can make improvements. We may remove information that
identifies you from this set of medical information so others may use it to study
health care and its delivery without learning who specific patients are. We may
also disclose your medical information to another health care provider or health
plan for quality assurance and case management, but only if they have or have
had a patient relationship with you.
We may use and disclose your medical information to contact you as a reminder
that you have an appointment.
Certain parts of our services are performed through contracts with Business
Associates that are outside service providers such as auditing, accreditation, legal
services, etc. At times it may be necessary for us to provide them with minimum necessary
medical information. The law requires that Business Associates maintain
the same level of security and privacy of your medical information.
Health-Related Benefits and Services
We may use and disclose your medical information to tell you about new products
or services, wellness information or recommend possible treatment options or
We may use limited information about you (i.e., name, address, phone number
and service dates) to compile a mailing or phone list to solicit contributions to
a fund\raising effort. You may opt-out of this by giving a written request to the
We must receive your authorization for any use or disclosure of your medical
information for marketing, except if the communication is face-to-face made by
Sale of Your Medical Information
We must have your authorization for any disclosure which is the sale of your
Medical Center Directory
You may be asked to be listed in the Medical Center Patient Directory. We may
use limited information about you (i.e., name, location, general condition and
religious affiliation) in the directory while you are being treated. This information
may be given to people who ask for you by name. This is so your family, friends
and clergy can contact you and find out how you are doing. You have the right,
during the registration process, to be excluded from the directory and restrict what
information is included.
Individuals Involved in Your Care or Payment for Your Care
We may release your medical information to a friend or family member who is
involved in your medical care or to someone who helps pay for your care. We may
also tell them about your condition and that you have been seen by us. In addition,
we may disclose your medical information to them should an emergent situation
arise while you are being treated.
Under certain circumstances we may use and disclose your medical information
for research purposes. For example, a research project to compare the health and
recovery of patients who received a medication to those who received another
or your medical information may be disclosed while reviewing its suitability for
a research project. In all cases where your specific authorization is not obtained,
your privacy will be protected by confidentiality requirements applied the by
representations of the researchers or their board.
As Required by Law
We will disclose your medical information when required to do so by federal, state
or local law.
To Avert a Serious Threat to Health or Safety
We may use and disclose your medical information when necessary to prevent a serious
threat to your health and safety, the health and safety of the public or another person.
Any disclosure would only be to someone able to help prevent the threat.
For All Other Uses and Disclosures
All other uses and disclosures of your medical information not contained in this
Notice will not be disclosed without your authorization.
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, eye and tissue procurement or to a donation
bank as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans
If you are a member of the armed forces, we may release your medical information as
required by military command authorities. We may also release medical information
about foreign military personnel to the appropriate foreign military authority.
We may release your medical information for workers’ compensation or similar
Public Health Risks
We may disclose your medical information 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 abuse or neglect; to report
reactions to medications or problems with products; to notify people of recalls
of products they may be using; to notify a person who may have been exposed
to a disease or may be at risk of 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 or authorized by law.
Health Oversight Activities
We may disclose your 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.
Lawsuits and Disputes
In response to a court order, subpoena, discovery request or other lawful
process by someone else involved in the dispute, we may disclose your medical
information, but only if efforts have been made to contact you about the request
or to obtain an order protecting the requested information.
We may release your medical information if asked to do so by a law enforcement
official: In response to a lawsuit or dispute; 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 obtain the person’s agreement; About a
death we believe may be the result of criminal conduct; About criminal conduct at
the health care facility; In emergency circumstances to report a crime; the location
of a 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 your medical information to a coroner or medical 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
medical center to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities
We may release your medical information to authorized federal officials for
intelligence, counterintelligence, and other national security activities authorized
Protective Services for the President and Others
We may disclose your medical information to authorized federal officials so they
may provide protection to the President, other authorized persons or foreign
dignitaries or conduct special investigations.
If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release your medical information to the correctional
institution or law enforcement official. This release would be necessary for the
institution to provide you with health care, to protect your health and safety or
the health and safety of others or for the safety and security of the correctional
Your Rights Regarding Medical Information about You
Right to Inspect and Request a Copy
You have the right to inspect and request a copy of the medical information that
may be used to make decisions about your care. This includes medical and billing
records but does not include psychotherapy notes. You must submit your request
in writing to the Privacy Officer. We may charge a fee for the costs 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 have the right to request that the denial be
reviewed by another licensed health care professional chosen by the medical
center who was not involved in the original denial. 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 medical center. Your amendment
request must be made in writing, with a supporting reason and submitted to
the Privacy Officer. We may deny your request for an amendment if it is not in
writing, does not include a reason to support the request or 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 the amendment; Is not part of the medical
information kept by or for the medical center; Is not part of the information which
you would be permitted to inspect and copy; Is accurate and complete.
Right to an Accounting or Disclosures
You have the right to request an accounting of certain disclosures of your medical
information made by us after April 14, 2003. 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 and
should indicate what form you want the list (for example, on paper, electronically,
etc.). The first list you request within a 12-month period will be free and we may
charge you for the costs of providing additional lists. 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 of your medical
information we use or disclose about your 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, like 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 and, 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 Privacy Officer and, in
your request, you must tell us what information you want to limit, whether you
want to limit our use, disclosure or both; and to whom you want the limits to
apply, for example, disclosures to your spouse.
Right to Restrict Release of Information for Certain Services
You have the right to restrict the disclosure of information to your health plan
regarding services for which you have paid out of pocket and in full.
Right to 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. For example, you can ask that we
only contact you at work or by mail. To request confidential communications, you
must make your request in writing to the Privacy Officer. We will accommodate
all reasonable requests. Your request must specify how or where you wish to be
Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice, even if you have agreed to receive
it electronically, by contacting the Privacy Officer. You may also obtain a copy of
this notice at our website www.seormc.org. To obtain a paper copy of this notice
please call the Privacy Officer.
Right to Breach Notification
You have the right to be notified of any breach of your unsecured health care
Changes to This Notice
We reserve the right to revise or change this Notice and to make the revised or
changed Notice effective for the 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 places of business listed in the ‘Who Will Follow This Notice’
section. The header of the Notice will contain the effective date. You will also
receive a copy each time you arrive for health care services.
Complaint and Contact Information
If you believe your privacy rights have been violated, you may file a complaint with
the medical center at 740-435-CARE (2273) or by email at firstname.lastname@example.org. You
may also file a complaint with the Secretary of the U.S. Department of Health and
Human Services in Washington D.C. in writing within 180 days of a violation of
your rights. You will not be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or
the laws that apply to us will be made only with your written permission. 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 uses and 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.
This Notice of Privacy Practices is effective, August 1, 2013, based on
the privacy practices originally implemented April 1, 2003 and updated
November 12, 2012. We must follow the privacy practices described in
this Notice; however, reserve the right to change our practices at any
time and apply these changes.
Notice of Privacy Practices