Notice of Information 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. If you have any questions about this notice or if you need more information, please contact our privacy officers:

Hospital

Jeannie Webster, RN/BSN, CMCO
400 Maple Summit Rd
Jerseyville, IL 62052
(618) 498-8312
jwebster@jch.org

Medical Group

John Giertz, CMPE
400 Maple Summit Rd,
Jerseyville, IL 62052
(618) 498-8343
jgiertz@jch.org

This Notice of Information Privacy Practices characterizes how Jersey Community Hospital (JCH) and Jersey Community Hospital Medical Group (JCHMG) may use and disclose your Protected Health Information (PHI) to implement treatment, payment or health care applications and for other objectives that are permitted or required by the law. JCH & JCHMG is required by law to maintain your PHI and to provide this notice explaining our privacy practices with regard to that information. This notice describes your rights to access and control your PHI that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

JCH & JCHMG is required to abide by the terms of this notice and reserves the right to change practices making new provisions effective for all PHI we maintain. Upon request a revised notice will be provided by calling or emailing the privacy officer listed above.

Understanding a Health Record/Information:

Each time a visit is made at JCH &/or JCHMG, a record is made. Typically, this record contains symptoms, examination, test results, diagnosis, treatment and a plan for further care or treatment. This information is referred to as your medical record. It serves as a:

• Basis for planning care and treatment
• Means of communication among health professionals who contribute to care
• Legal document describing care that was received
• Means to verify by the person who received treatment and/or a third-party payer services billed and provided.
• An educational tool for health care professionals
• A source of data for medical research
• A source of information for public health officials who oversee the delivery of health care in the United States
• A source of data for facility planning and marketing
• A tool to assess and continually work to make improvements in the care JCH & JCHMG renders and the outcomes to achieve.

Understanding what is in a medical record and how health information is utilized helps to ensure accuracy, better understand who, what, when, where, and why others may need access to private health information and allow more informed decisions when authorizing disclosure to others. Disclosure of health information without proper authorization will not be permitted except as described in this notice.

How JCH &/or JCHMG Will Use or Disclose Health Information

• For Treatment. JCH & JCHMG may use or disclose your PHI to provide medical treatment or services that will assist in managing and integrating your medical care during your stay. This includes the coordination or management of your health care with another provider. For example, information obtained by a nurse, physician, or other member of the healthcare team will be recorded in the record and used to determine the course of treatment that should work best for you. Your physician will document in the record his or her expectations of the members of the healthcare team. Members of the healthcare team will then record the actions they take and their observations. In that way, the physician will know the response in treatment. The physician and/or subsequent healthcare provider will be provided with copies of various reports that will assist in treatment after discharge from the hospital. This includes disclosure of PHI, as necessary, to a home health agency, nursing home or rehab facility that may provide care post discharge.
• For Payment. Patient PHI will be disclosed and used, as needed, for payment of health care services provided by JCH &/or JCHMG or by another provider. This may include certain activities that health insurance plans may undertake before it approves or pays for the health care services recommended such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided for medical necessity and undertaking utilization review activities. For example, obtaining endorsement for a hospital admission may require relevant PHI to be disclosed to the health plan indicated for approval for hospital admission.
• For Health Care Operations. JCH & JCHMG my use or disclose, as needed, PHI to support the business activities for regular health operations of the hospital. For example, members of the medical staff, the risk or quality improvement team may use information in the health care record to assess the care and outcomes in similar and alike cases. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and services the hospital provides. JCH & JCHMG may also disclose information to physicians, nurses, medical technicians, medical students, and other authorized personnel for educational and learning purposes.
• Business Associates. There are some services provided in our organization through contacts with third party “business associates”. Examples include our accountants, consultants and attorneys. Whenever an arrangement between the hospital and a business associate involves the use or disclosure of PHI, a written contract that contains terms to ensure the protection and privacy of all health information is obtained.
• Data Breach Notification Purposes. JCH & JCHMG may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information. You have the right to be notified upon a breach of any of your unsecured PHI.
• Health Oversight Activities. JCH & JCHMG may disclose PHI to a health oversight agency for activities authorized by law. For example, audits, investigations, inspections, licensure, and similar activities that is necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
• Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
• Minors. We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.
• Funeral Directors. We may disclose PHI to funeral directors, coroners and/or medical examiners for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.
• Organ Procurement Organizations. Consistent with applicable law, we may disclose PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• Appointment Reminders/Health-Related Benefits and Services. JCH & JCHMG may use and disclose PHI for appointment reminders for medical care or for available treatment options, alternative care or health related benefits and services.
  Food and Drug Administration (FDA). JCH & JCHMG may disclose to the FDA PHI relative to quality, safety or effectiveness with respect to food, medications, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
• Public Health. As required by law, JCH & JCHMG may disclose PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability. This includes reported births and deaths, child abuse or neglect and a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• Abuse, Neglect, or Domestic Violence. JCH & JCHMG may disclose PHI to the appropriate government authority or agency if we believe that a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or the facility is required or authorized by federal or state law to make that disclosure.
• Workers Compensation. JCH & JCHMG may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established for work-related injuries or illness.
• Law Enforcement. JCH & JCHMG may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. Law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency and it is likely that a crime has occurred (not on hospital premises).
• Criminal Activity. Consistent with applicable federal and state laws, JCH & JCHMG may disclose PHI, if there is a belief that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. JCH & JCHMG may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
  Correctional Institution. JCH & JCHMG may disclose to a correctional institution or agents thereof PHI necessary for health care of an inmate and the health and safety of other individuals employed or imprisoned at the institution.
• Lawsuits and Disputes. Involvement in a lawsuit or a dispute may require disclosure of PHI in response to a court or administrative order. PHI may also be disclosed in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell the involved person about the request or to get orders protecting the information requested. JCH & JCHMG may also use or disclose an individual’s PHI to defend the hospital &/or clinic site in the event of a lawsuit.
• Active Military, National Security and Veterans. When the appropriate conditions apply, JCH & JCHMG may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if the individual is a member of that foreign military services. JCH & JCHMG may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Uses and Disclosures of PHI Based Upon Written Authorization

Other uses and disclosures of PHI will be made only with written authorization, unless otherwise permitted or required by law as described. Revocation of this authorization in writing is permitted at any time and disclosure of PHI will no longer be used for the reasons covered. Please understand that JCH & JCHMG is unable to take back any disclosures already made with prior authorization.

Other Permitted and Required Uses and Disclosures that Require Providing You an Opportunity to Agree or Object.

JCH & JCHMG may use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.

• Fundraising. JCH & JCHMG may contact you using PHI as part of a fund-raising effort as necessary. You have the right to deny or refuse any fundraising communications. If you do not wish to receive these materials, please submit a written request to the Privacy Officer.
• Disaster Relief. Disclosure of an individual PHI to disaster relief organizations to coordinate care or notify family and friends of an individual’s location or condition in a disaster may occur. An individual may agree or object to such a disclosure whenever we practicably can do so.
• For the Denomination Directory. Unless stated objection to clergy register, JCH & JCHMG may list your name, location in the facility, and religious affiliation for directory purposes for spiritual care during admission.
• Notification. JCH & JCHMG may use or disclose information to notify or assist in notifying another person responsible for your care, such as a Power of Attorney for Healthcare, your location and general condition unless you object. Health care professionals my use their best judgment in disclosure of PHI relevant to care and payment of related care to a family member, other relative, close personal friend or any other person identified.

Your Rights.

Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.

You Have the Right to Inspect and Copy Your PHI.

This means you may inspect and obtain a copy of PHI about you for so long as JCH & JCHMG maintains the PHI. You may obtain your medical record that contains medical and billing records and any other records that your physician and the hospital use for making decisions about your health and care. As permitted by federal or state law, JCH & JCHMG may charge you a reasonable copy fee for a copy of your records and has up to 30 days to make your PHI available. We may not charge you a fee if the information is needed for a claim for benefits under the Social Security Act or any other state or federal needs based benefit program. JCH & JCHMG may deny your request in certain limited circumstances. If your request has been denied, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and JCH & JCHMG will comply with the outcome of the review.

You Have a Right to a Summary or Explanation.

JCH & JCHMG can provide you with a summary of your PHI, rather than the entire record, or you can be provided with an explanation of the PHI which has been provided to you, so long as you agree to this alternative form and pay the associated fees.

You have a right to an Electronic Copy of Your Medical Record.

You have the right to request an electronic copy of your record to be sent to you or transmitted to another individual or entity. If the PHI is not readily producible in the form or format you have requested, your record will then be provided in either our standard electronic format or in a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record. JCH & JCHMG will attempt to accommodate reasonable requests made for communication of health information by alternative means and to notify you if we are unable to agree to a requested restriction.

You Have the Right to Request Amendments.

As long as JCH & JCHMG maintains your designated medical record, you have the right to request to amend your PHI if you feel that there is incorrect or incomplete information entered in it. A request for amendment must be made in writing to Medical Records and it must explain the reason to support your request for the amendment. We ask that you use the form provided by our facility that is located on our web site at www.jch.org to make your request(s) for your medical record information. If unable to access form, you may contact the Medical Records Director at the hospital at (618) 498-8474 or for the clinic sites at (618) 498-2101.

You Have the Right To an Accounting of Disclosures.

You may request that we provide you with a written accounting of all disclosures of your PHI made by us during the time period for which you request (not to exceed 6 years). We ask that such requests be made in writing on a form provided by our facility. Please note that an accounting will not apply to any of the following types of disclosures: disclosures made for reasons of treatment, payment or health care operations; disclosures made to you or your legal representative, or any other individual involved with your care; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee.

You Have the Right to Request Restrictions.

You have the right to request a restriction or limitation on the PHI used or disclosed for treatment, payment or health care operations. You also have the right to request a limit on the PHI disclosed about you to another entity who is involved in your care or the payment for your care. To request a restriction on who may have access to your PHI, a written request must be submitted to Medical Records stating the specific restriction requested and to whom you want the restriction to apply to. We are not required to agree to your request, unless you are asking to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid JCH &/or JCHMG in full “out-of-pocket”. If requested restriction is granted we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.

• Out-of-Pocket-Payment. If you paid in full for your services that were rendered at JCH &/or JCHMG out-of-pocket, you have the right to ask that your PHI with respect to that service not to be disclosed to a health plan for purposes of payment or health care operations, and we will abide by that request.

You Have the Right to Request Confidential Communications.

You have the right to request how communication with you shall be maintained in order to preserve your privacy. For example, you may request that we contact you by mail at a specified address or utilize a designated phone number. You must make any such request in writing specifying how or where we are to maintain contact with you. We will accommodate all reasonable requests.

You have the right to obtain a paper copy of our Notice of Information Privacy Practices upon request at any time.

Changes To This Notice.

JCH & JCHMG reserves the right to change this Notice. We reserve the right to make the changed Notice effective for Protected Health Information we already have as well as for any Protected Health Information we create or receive in the future.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Privacy Officer listed at the beginning of this notice or you may also contact our facility’s Medical Record Director at (618) 498-8474.

Complaints. You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated.

Secretary of the U.S. Department of Health and Human Services
200 Independence Ave.
S.W. Washington, D.C. 20201
(202) 619-0257 or toll free (877) 696-6775

To file a complaint with us, contact our Privacy Officer at the address listed at the beginning of this Notice. All complaints must be made in writing and should be submitted within 180 days of when you became knowledgeable of the suspected violation. There will be no retaliation for filing a complaint. For more information you may go to the website of the Office for Civil Rights at www.hhs.gov.

Effective Date: April 14, 2003. Revised April 21, 2014. Revised April 4, 2016.