NOTICE OF PRIVACY PRACTICES

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.

Treatment Your health information may be used by Good Samaritan Hospital Association (GSHA) staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.For example, results of laboratory results and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted to assist with your treatment.

Payment
Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services.For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition that was treated.

Law Enforcement
Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement activities, and to comply with government mandated reporting.

Public health records
Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization
Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization.If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Appointment reminders
Your health information may be used by our staff to contact you with appointment reminders.

Information about treatments
Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.

Fund raising
Unless you request us not to, we will use your name and address to support our fund raising efforts. If you do not want to participate in fund raising efforts, please notify the HIPAA Privacy Officer at 701-776-5261 ext 253.

• the right to request restrictions on the use and disclosure of your protected health information (PHI)
• the right to receive confidential communications concerning your medical condition and treatment
• the right to inspect and/or obtain copies of your PHI
• the right to request amendment or submit corrections to your PHI
• the right to receive an accounting of how and to whom your PHI has been disclosed
• the right to receive a printed copy of this notice.

GSHA’s Duties

We are required by law to maintain the privacy of your PHI and to provide you with this notice of privacy practices.We also are required to abide by the privacy policies and procedures that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices.These changes in our policies and practices may be required by changes in federal and state laws and regulations.Whatever the reason for these revisions, we will provide you with a revised notice on your next visit or upon a request from you.The revised policies and practices will be applied to all PHI that we maintain.

Requests to Inspect PHI

As permitted by federal regulations, we require that requests to inspect or obtain copies of PHI be submitted in writing.You may obtain a form to request access to your records by contacting Health Information Services or the HIPAA Privacy Officer.

If you believe that your privacy rights have been violated, you should call the matter to our attention by either completing a Privacy Practices Complaint for or by sending a letter describing your concerns to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Heart of America Medical Center
Attn HIPAA Privacy Officer
800 S Main Ave
Rugby ND 58368
Phone: 701-776-5261 ext 253

Effective Date:
This Notice of Privacy Practices is effective on or after April 14, 2003.