Patient Privacy

Good Samaritan Hospital Notice of Privacy Practices

This notice describes how medical information about you may be disclosed and how you can get access to this information. Please review it carefully.

The terms of this Notice of Privacy Practices apply to Good Samaritan Hospital operating as a clinically integrated health care arrangement composed of Good Samaritan Hospital and all its outpatient sites, physicians, and other licensed professionals seeing and treating patients at Good Samaritan Hospital and its outpatient facilities. A complete listing of our service locations is available upon request. The members of this clinically integrated health care arrangement will share personal health information of our patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients’ personal health information and to provide patients with notice of our legal duties and privacy practices with respect to their personal health information. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all personal health information maintained by us. You may receive a copy of any revised notices at the Patient Relations Department or a copy may be obtained by mailing a request to Patient Relations, Good Samaritan Hospital, 2222 Philadelphia Drive, Dayton, Ohio 45406.
Uses and Disclosures of Your Personal Health Information

Your Authorization

Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.

Uses and Disclosures for Treatment

We will use and disclose your personal health information as necessary for your treatment. For instance, doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, tests, etc. We may also release your personal health information to another health care facility or professional who is not affiliated with our organization but who is or will be providing treatment to you. For instance, if, after you leave the hospital, you are going to receive home health care, we may release your personal health information to that home health care agency so that a plan of care can be prepared for you.

Uses and Disclosures for Payment

We will use and disclose your personal health information as necessary for payment purposes of those health professionals and facilities that have treated you or provided services to you. For instance, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you or we may use your information to prepare a bill to send to you or to the person responsible for your payment.

Uses and Disclosures for Health Care Operations

We will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations which include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your personal health information to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with you.

Our Facility Directory

We maintain a facility directory listing the names and room numbers of patients. Unless you choose to have your information excluded from this directory, this information will be disclosed to anyone who requests it by asking for you by name. You have the right during registration or at any time during your hospitalization to request that your information be excluded from this directory and also to restrict what information is provided and/or to whom.

Family and Friends Involved In Your Care

With your approval, we may from time to time disclose your personal health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with such individuals without your approval. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Business Associates

Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may be necessary for us to provide certain components of your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.

Fundraising

We may contact you to donate to a fundraising effort for or on our behalf. You have the right to “opt-out” of receiving fundraising materials/communications and may do so by sending your name and address to Good Samaritan Hospital Foundation - Dayton, 2222 Philadelphia Drive, Dayton, Ohio 45406, together with a statement that you do not wish to receive fundraising materials or communications from us.

Appointments and Services

We may contact you to provide appointment reminders or test results. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing and may send your request to Patient Relations, Good Samaritan Hospital, 2222 Philadelphia Drive, Dayton, Ohio 45406, and/or the outpatient center where you receive care.

Health Products and Services

We may from time to time use your personal health information to communicate with you about health products and services necessary for your treatment, to advise you of new products and services we offer, and to provide general health and wellness information.

Research

In limited circumstances, we may use and disclose your personal health information for research purposes. For example, a research organization may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of patient information.
 
Confidentiality of Alcohol and Drug Abuse Patient Records

The confidentiality of alcohol and drug abuse patient records maintained by this facility is protected by federal law and regulations. Generally, the facility may not say to a person outside the program that you attend a drug or alcohol program, or disclose any information identifying you as an alcohol or drug abuser unless: (1) you consent in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Federal law and regulations do not protect information about a crime committed by you either at our facility or against any person who works for the facility or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

Other Uses and Disclosures

We are permitted or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization.

• We may release your personal health information for any purpose required by law
• We may release your personal health information for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations
• We may release your personal health information as required by law if we suspect child abuse or neglect; we may also release your personal health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence
• We may release your personal health information to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls
• We may release your personal health information to your employer when we have provided health care to you at the request of your employer to determine workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer
• We may release your health information if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings
• We may release your personal health information if required to do so by subpoena or discovery request; in most cases you will have notice of such release
• We may release your personal health information to law enforcement officials as required by law to report wounds and injuries and crimes
• We may release your personal health information to coroners and/or funeral directors consistent with law
• We may release your personal health information if necessary to arrange an organ or tissue donation from you or a transplant for you
• We may release your personal health information if in limited instances we suspect a serious threat to health and safety
• We may release your personal health information if you are a member of the military as required by armed forces services; we may also release your personal health information if necessary for national security or national intelligence activities
• We may release your personal health information to workers’ compensation agencies if necessary for your workers’ compensation benefit determination

Rights That You Have

Access to Your Personal Health Information

You have the right to copy and/or inspect much of the personal health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. We will charge you per page if you request a copy of the information. We will also charge for postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such summary. You may obtain an access request form from the Health Information Services department.

Amendments to Your Personal Health Information

You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/ correction request. If any amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form from the Health Information Services department.

Accounting for Disclosures of Your Personal Health Information

You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your representative. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of Your Personal Health Information

You have the right to request restrictions on certain of our uses and disclosures of your personal health information for treatment, payment, or health care operations. Requests must be made in writing and signed by you or your representative. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate and we retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such termination notice to Health Information Services, Good Samaritan Hospital, 2222 Philadelphia Drive, Dayton, Ohio 45406.

Complaints

If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer, 40 W. Fourth St., Suite 1850, Dayton, Ohio 45402. 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. There will be no retaliation for filing a complaint.

Acknowledgment of Receipt of Notice

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

For Further Information

If you have questions or need further assistance regarding this Notice, you may contact Patient Relations, Good Samaritan Hospital, 2222 Philadelphia Drive, Dayton, Ohio 45406, (937) 734-1000.

As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means.

A complete listing of our service locations is available by sending a request to the Privacy Officer, 40 W. Fourth St., Suite 1850, Dayton, Ohio 45402.

Effective Date

This Notice of Privacy Practices is effective April 14, 2003.