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.

If you have any questions about this notice, please contact the Facility Privacy Officer at the phone number or address listed at the bottom of this notice.

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment, and billing related information. We understand that medical information about you is personal. We are committed to protecting medical information about you. This notice applies to all the records of your care generated by the hospital whether made by hospital personnel, agents of the hospital, 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 doctor's office or clinic.

We are required by law to maintain the privacy of your health information and provide you a description of our policy practices. We will abide by the terms of the privacy notice that is currently in effect.

Uses and Disclosures of Medical Information About You

• For Treatment: We may use medical information about you to provide you treatment or services. 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 Madison Community Hospital. For example: a doctor treating you for an injury may need to know if you have diabetes, because diabetes may slow the healing process, or if your doctor orders physical therapy, the nursing staff will need to discuss your care and treatment with the physical therapist. Different departments of Madison Community Hospital also may share medical information about you in order to coordinated the different things you may need, such as prescriptions, lab work, meals, and x-rays. We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him/her in treating you once you are discharged from Madison Community Hospital.
• For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company, or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.
• For Health Care Operations: Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. For example, we may combine medical information about many patients to evaluate the need for new services, treatment, or equipment. We may disclose information to doctors, nurses, and other students for educational purposes.

We also may contact you or use and disclose information about you:

• To remind you of appointments for medical care
• To assess your satisfaction with our services
• To tell you about possible treatment
• To tell you about health-related benefits or services
• To contact you as part of fund raising efforts
• For population-based activities relating to improving health or reducing health care costs
• For conducting training programs and reviewing competence of health care professionals

You medical information may be used without your prior authorization for several other reasons including:

• Business Associates: There are some services provided in our organization through contracts with business associates such as computer software vendors or electronic billing services. 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 if necessary, bill you or your third party for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
• Affiliated Covered Entity: Protected health information will be made available to your physician and other affiliated covered entities as necessary to carry out treatment, payment and health care operations.
• Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
• Coroners and medical examiners: This may be required by law in certain circumstances and/or may be necessary to identify a deceased person or determine the cause of death.
• Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability
• Reporting Adverse Events: We may disclose health information relative to adverse events with respect to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs, or replacement.
• Reporting Vital Events: As required by law, we may disclose your health information to record events such as birth or death.
• Law Enforcement: To help identify or locate a suspect, fugitive, witness or missing person. Other examples would include information about a death suspected to be the result of criminal conduct.
• Law Suits or Other Legal Proceedings: In response to a court order, warrant, summons, or subpoena.
• Health Oversight Activities: This would include activities such as licensing, auditing or inspection agencies authorized by law.
• Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
• Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, health information necessary for your health, and the health and safety of other individuals.
• Military or Veterans: If you are or were a member of the armed forces, we may release information about you to military command authorities as required or authorized by law.

If admitted as a patient, unless you tell us otherwise, we will:

• List in the patient directory: We may include certain limited information about you in the Facility directory while you are here. The information may include your name, location in the facility, your general condition (e.g. fair, stable, etc.) 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.
• Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. 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.

Other uses of medical information

In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.

Your rights regarding medical information about you

Although your health record is the physical property of Madison Community Hospital, you have the following rights regarding medical information we maintain about you:

• Inspect and Copy: In most cases, 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 include psychotherapy notes. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. 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.
• Amend: If you feel that medical information we have about you is incorrect or incomplete, you may request that we amend the information. The request must be submitted in writing and must provide your reason for requesting the amendment. You have the right to request an amendment for as long as the information is kept by our facility. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
• An Accounting of Disclosures: You have the right to request a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure. This request must be submitted in writing. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the fee upon request.
• Request Restrictions: You have the right to request a restriction or limitations 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 payment for your care, like a family member or friend. 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.
• Request Confidential Communications: You have the right to request that we communicate about medical matters in a certain way or at an alternate location. We will not request an explanation. We will agree to the request to the extent that it is reasonable for use to do so. For example, you can ask that we use an alternative address for billing purposes.
• 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.
• Changes to This Notice: We reserve the right to change this notice at any time. Changes will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the hospital and on our website at www.madisonhospital.com. You can receive a copy of the current notice at any time. Upon your initial visit, you will also be asked to acknowledge in writing your receipt of this notice.

All written request or appeals should be submitted to our Privacy Office listed at the bottom of this notice.

Complaints

If you believe your privacy rights have been violated or you disagree with a decision we made about access to your records, you may contact our Privacy Office (listed below). You may also send a written complaint to the United States Department of Health and Human Services Office of Civil Rights. Our Privacy Office can provide with the address. Under no circumstances will you be penalized or retaliated against for filing a complaint. All complaints must be submitted in writing.