Legal Statement

NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003

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.

We at Mercy are required by law to maintain the privacy of individually identifiable patient health information (this information is “protected health information” and is referred to herein as “PHI”). We are also required to provide patients with a Notice of Privacy Practices regarding PHI. We are required to post this Notice in a prominent place within our facility. We will only use or disclose your PHI as permitted or required by applicable state law. This Notice applies to your PHI in our possession including the medical records generated by us.

Mercy understands that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how we will use and disclose your PHI.

This Notice applies to the delivery of health care by Mercy and its medical staff in the main hospital, outpatient departments, TCU, Mercy Home Care and Hospice, Bluff Terrace, Wyndcrest, Harmony House, and Mercy Home Medical Equipment. This Notice also applies to the utilization review and quality assessment activities of our parent company and Mercy as a member of our corporation, a Catholic health care system with facilities in 7 states.

Permitted Use or Disclosure

Treatment: Mercy will use and disclose your PHI in the provision and coordination of heath care to carry out treatment functions.

Mercy will disclose all or any portion of your patient medical record information to your attending physician, consulting physician(s), nurses, technicians, medical students and other health care providers who have a legitimate need for such information in your care and continued treatment.
Mercy is a Catholic sponsored health care provider. Spiritual care providers are members of our care staff and will be a part of our team of care providers who use your medical information to provide health care services to you when you are in our facilities.

Different departments will share medical information about you in order to coordinate specific services, such as lab work, x-rays and prescriptions.

Mercy also will disclose your medical information to people or entities outside Mercy who will be involved in your medical care after you leave, such as family members, clergy and others who will provide services that are part of your care.

Mercy will share certain information such as your name, address, employment, insurance carrier, emergency contact information and appointment scheduling information in an effort to coordinate your treatment with us and with other health care providers.

Mercy will use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.

Mercy will use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at our facility.

If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Mercy will disclose your PHI to the correctional institution or law enforcement official.

Payment: Mercy will disclose PHI about you for the purposes of determining coverage, eligibility, funding, billing, claims management, medical data processing, stop loss / reinsurance and reimbursement.

The medical information will be disclosed to an insurance company, third party payer, third party administrator, health plan or other health care provider (or their duly authorized representatives) involved in the payment of your medical bill and will include copies or excerpts of your medical records which are necessary for payment of your account. It will also include sharing the necessary information to obtain pre-approval for payment for treatment from your health plan.
Mercy will disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.

Health Care Operations: Mercy will use and disclose your PHI during routine health care operations including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities at Mercy, and for educational purposes.

For instance, Mercy will need to share your demographic information, diagnosis, treatment plan and health status for population based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, and contacting health care providers and patients with information about treatment alternatives, in order for us to operate our business in an efficient, safe and legal manner.

Other Uses and Disclosures: As part of treatment, payment and health care operations, we may also use your PHI for the following purposes:

Fundraising Activities: Mercy may use and may also disclose some of your PHI to a related foundation for certain fund raising activities. For example, Mercy may use your demographic information (e.g., name, address and other contact information, age, gender, and insurance status) and the dates we provided service to you. Any communication sent to you that uses this information will let you know how you may opt out of receiving similar communications in the future. Mercy may disclose limited PHI to a company contracted to conduct fundraising for the us This company will use your PHI only for the purposes of fundraising for Mercy. (If you wish to opt-out, you may do so by contacting the Mercy Foundation at 563-244-3535)

Medical Research: Mercy may disclose your PHI without your Authorization to medical researchers who request it for approved medical research projects; however, with very limited exceptions such disclosures must be cleared through a special approval process before any PHI is disclosed to the researchers. Researchers will be required to safeguard the PHI they receive.
Information and Health Promotion Activities: Mercy will use and disclose some of your PHI for certain health promotion activities. For example, your name and address will be used to send you newsletters or general communications.

Mercy will also send you information based on your own health concerns and it has determined that a product or service may help you. The communication will explain how the product or service relates to your well being and can improve your health.

Wyndcrest, Bluff Terrace and Harmony House are the homes of our long term care residents. Resident’s name and location are made available in public areas as well as the Facility Directory and names posted outside resident rooms to allow residents to easily find their room and relatives and friends to visit. Social activities include publishing of birthdays and pictures within the facility as well as the newsletter. You may opt out of the Facility Directory or request that no PHI be made available including birth dates and postings outside of resident rooms by contacting Services for Aging at 563-244-3881 for Wyndcrest and 563-244-3706 at Bluff Terrace/Harmony House. Law requires that we electronically transmit copies of your healthcare assessment to the Centers for Medicaid and Medicare Services (CMS) State Repository. This information is also used for accreditation organizations to measure our quality of care performance.

More Stringent State and Federal Laws: The State law of Iowa is more stringent than HIPAA in several areas. State law is more stringent when the individual is entitled to greater access to records than under HIPAA and when under state law the records are more protected from disclosure than under HIPAA. Certain federal laws also are more stringent than HIPAA. Mercy will continue to abide by these more stringent state and federal laws. The federal laws include applicable internet privacy laws, such as the Children’s Online Privacy Protection Act and the federal laws and regulations governing the confidentiality of health information regarding substance abuse treatment.

IOWA LAW:

ACCESS TO PHI – Iowa law requires that access to PHI by a nursing home resident, skilled nursing home or rehab patient be allowed within 24 hours and may obtain a copy within 48 hours.

SUBSTANCE ABUSE – Minors, acting on their own, may seek substance abuse treatment. A minor must authorize the release of any PHI in this instance.

SEXUALLY TRANSMITTED DISEASES – A minor may seek treatment for sexually transmitted diseases.

ILLINOIS LAW: (When Home Care Services are provided in Illinois)
In Illinois, subject to certain exceptions, the nature or details of services provided to a patient cannot be disclosed to anyone (other than the patient or his / her designee) without the patient’s authorization. Exceptions: persons directly involved in treating the patient or processing the payment for treatment; persons responsible for peer review, utilization review or quality assurance; suspected child abuse or neglect; and where authorized by law.

Permitted Use or Disclosure with an Opportunity for You to Agree or Object

Family/Friends: Mercy will disclose PHI about you to a friend or family member who is involved in your medical care. We will also give information to someone who helps you pay for your care. In addition, we will disclose PHI about you to an agency assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You have a right to request that your PHI not be shared with some or all of your family or friends.

Mercy Directory: We will include certain limited information about you in our facility Directory while you are a hospital patient here. This information will include your name, location in the facility, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation. This is
so your family and friends can visit you here and know how you are doing. The directory information, except for your religious affiliation, will also be disclosed to people who ask for you by name. You have the right to request that your name not be included in the Directory. If you request to opt out of the Directory, we cannot inform visitors of your presence, location, or general condition.

Spiritual Care: Directory information including your religious affiliation will be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. It is our policy, however, not to notify your local religious organization that you are in Mercy, unless you request we do so. Spiritual care providers are members of the health care team at Mercy and may visit you after you have been admitted. A spiritual care provider may be called in to consult regarding your care. You have a right to request that your name not be given to any member of the clergy.

Promotional Communications: Mercy does not share or sell your PHI to companies that market health care products or services directly to consumers for use by those companies to contact you, such as drug companies. We do maintain a database of individuals for promotional communications, disease management, health promotion, and fundraising purposes. This database includes individuals to whom Mercy may have sent health improvement materials and news previously and also individuals who have donated to Mercy or who have expressed an interest in doing so, as well as health-related activities. You may be included in this database. Mercy sends information to the individuals in this database about the programs and services we offer here. If you wish to be deleted from this database, you may notify the Privacy Official at 563-244-3861.

Media Conditions Reports: Mercy may release information for an update to the media if the media requests information about you using your full name and after we have given you an opportunity to agree or object. The following information may then be disclosed: your condition described in general terms that do not communicate specific medical information, such as “good”, “fair”, “serious”, or “critical”.

Use or Disclosure Requiring Your Authorization

Marketing: Mercy is not permitted to provide your PHI to any other person or company for marketing to you of any products or services other than the our own products or services unless you have signed an authorization.

Research: Mercy will use or disclose your PHI as part of research that includes providing you with treatment. For example, if you are part of a research study that includes treatment, Mercy may require that you sign an authorization to allow the researchers to use or disclose your PHI for this research.

Other Uses: Any uses or disclosures that are not for treatment, payment or operations and that are not permitted or required for public policy purposes or by law will be made only with your written authorization. Written authorizations will let you know why we are using your PHI. You have the right to revoke an authorization at any time.

Use or Disclosure Permitted by Public Policy or Law without your Authorization

Law Enforcement Purposes: Mercy will disclose your PHI for law enforcement purposes as required by law, such as responding to a court order or subpoena, identifying a criminal suspect or a missing person, or providing information about a crime victim or criminal conduct.

Required by Law: Mercy will disclose PHI about you when required by federal, state or local law to make reports or other disclosures. We also will make disclosures for judicial and administrative proceedings such as lawsuits or other disputes in response to a court order or subpoena. Mercy will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violence. We will report drug diversion and information related to fraudulent prescription activity to law enforcement and regulatory agencies. Specialized government functions will warrant the use and disclosure of PHI. These government functions will include military and veteran’s activities, national security and intelligence activities, and protective services for the President and others. Mercy will make certain disclosures that are required in order to comply with workers’ compensation or similar programs.

Coroners, Medical Examiners, Funeral Directors: Mercy will disclose your PHI to a coroner or medical examiner. For example, this will be necessary to identify a deceased person or to determine a cause of death. Mercy will also disclose your medical information to funeral directors as necessary to carry out their duties.

Organ Procurement: Mercy will disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes.

Health or Safety: Mercy will use and disclose PHI to avert a serious threat to health and safety of a person or the public. We will use and disclose PHI to Public Health Agencies for immunizations, communicable diseases, etc. We will use and disclose PHI for activities related to the quality, safety or effectiveness of FDA-regulated products or activities, including collecting and reporting adverse events, tracking and facilitating product recalls, etc. and post marketing surveillance. Any patient receiving a medical device subject to FDA tracking requirements may refuse to disclose, or refuse permission to disclose, their name, address, telephone number and social security number, or other identifying information for the purpose of tracking.

V. Your Health Information Rights

Although we at Mercy must maintain all records concerning your hospitalization and treatment by the us, you have the following rights concerning your PHI:

Right to Inspect and Copy: You have the right to access your PHI and to inspect and receive a copy your PHI as long as we maintain it except for: psychotherapy notes, information that will be used in a civil, criminal or administrative action or proceeding, and where prohibited or protected by law. Mercy will deny your request for access to your PHI without giving you an opportunity to review that decision if:

• You don’t have the right to inspect the information; or it is otherwise prohibited or protected by law;
• You are an inmate at a correctional institution and obtaining a copy of the information would risk the health, safety, security, custody or rehabilitation of you or other inmates;
• The disclose of the information would threaten the safety of any officer, employee or other person at the correctional institution or who is responsible for transporting you;
• You are involved in a clinical research project and Mercy created or obtained the PHI during that research. Your access to the information will be temporarily suspended for as long as the research is in progress;
• Mercy obtained the information that you seek access to from someone other than the health care provider under a promise of confidentiality and your access request is likely to reveal the source of the information; or
• Under other limited circumstances. In these instances, however, Mercy will allow the review of its decision by a health care professional that we have chosen. This person will not have been involved in the original decision to deny your request.

You agree to pay a reasonable copying charge. You must make your requests to access and copy your PHI in writing to Mercy. We will respond to your request within 30 days of its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 60 days of its receipt.

Right to Amend: You have the right to amend your PHI for as long as Mercy maintains it. However, we will deny your request for amendment if:

• We did not create the information;
• The information is not part of the designated record set;
• The information would not be available for your inspection (due to its condition or nature); or
• The information is accurate and complete.

If we deny your request for changes in your PHI, we will notify you in writing with the reason for the denial. We will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that Mercy include your request for amendment and the denial any time that we disclose the information that you wanted changed. We may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.

You must make your request for amendment of your PHI in writing to Mercy, including your reason to support the requested amendment. We will respond to your request within 60 days of its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which the we will act
on your request. In any event, we will act on your request within 90 days of its receipt.

Right to an Accounting: You have a right to receive an accounting of the disclosures of your PHI that we have made, except for the following disclosures:
To carry out treatment, payment or health care operations;
To you;
To persons involved in your care;
For national security or intelligence purposes;
To correctional institutions or law enforcement officials; or
Disclosures that occurred prior to April 14, 2003.

For each disclosure, you will receive: the date of the disclosure, the name of the receiving organization and address if known, a brief description of the PHI disclosed and a brief statement of the purpose of the disclosure or a copy of the written request for the information, if there was one.

You must make your request for an accounting of disclosures of your PHI in writing to Mercy. You must include the time period of the accounting, which may not be longer than 6 years. We will respond to your request within 60 days from its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 90 days of its receipt.

In any given 12-month period, Mercy will provide you with an accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting within that time period will be subject to a reasonable fee for preparing the accounting.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or health care operations functions or to prohibit such disclosure. However, we will consider your request but are not required to agree to the requested restrictions.

You also have an additional right to limit the release of PHI to family, friends, or in the facility directory. For example, you may ask that your name not be used in the waiting room or that information about your expected discharge date not be shared with your family.

Right to Confidential Communications: You have the right to receive confidential communications of your PHI by alternative means or at alternative locations. For example, you may request that Mercy only contact you at work or by mail.

Right to Receive a Copy of this Notice: You have the right to receive a paper copy of this Notice of Privacy Practices, upon request.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Mercy or with the Secretary of the Department of Health and Human Services. To file a complaint with Mercy, please contact our Privacy Officer at 563-244-3861. All complaints must be submitted in writing directly to Mercy’s Privacy Official. Mercy assures you that there will be no retaliation for filing a complaint.

Sharing and joint use of your Health Information

In the course of providing care to you and in furtherance of the Mercy’s mission to improve the health of the community, we will share your PHI with other organizations as described below who have agreed to abide by the terms described below:

Medical Staff: The medical staff and Mercy participate together in an organized health care arrangement to deliver health care to you at the Mercy. Both Mercy and its medical staff have agreed to abide by the terms of this Notice with respect to PHI created or received as part of delivery of health care services to you in Mercy. Physicians and allied health care providers are members of the Mercy’s medical staff and will have access to and use your PHI for treatment, payment and health care operations purposes related to your care within the Mercy. We will disclose your PHI to the medical staff for payment, treatment and health care operations.

Business Associates: Mercy will use and disclose your PHI to business associates contracted to perform business functions on its behalf including our parent company who performs certain business functions for us. Whenever an arrangement between Mercy and another company involves the use or disclosure of your PHI, that business associate will be required to keep your information confidential.

Membership in our Corporation:
Mercy and members of our corporation participate together in an organized health care arrangement for utilization review and quality assessment activities. We have agreed to abide by the terms of this Notice with respect to PHI created or received as part of utilization review and quality assessment activities of our corporation and its members. Members will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or healthcare operations. As a part of a national Catholic health care system, Mercy and other hospitals, nursing homes, and health care providers in our corporation share your PHI for utilization review and quality assessment activities of the parent company, and its members. Members also use your PHI for your treatment, payment to Mercy and/or for the health care operations permitted by HIPAA with respect to our mutual patients.

Additional Information

For further information regarding the issues covered by this Notice of Privacy Practice, please contact: Kathy McAllister at 563-244-3861 or by email at CLPrivacyOfficer@mercyhealth.com.

Changes to this Notice

Mercy will abide by the terms of the Notice currently in effect. We reserve the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. Mercy will provide you with the revised Notice upon your request.

MERCY MEDICAL CENTER - CLINTON
Notice of Privacy Practices Summary

This summary describes how we use and share information about you. This summary describes how you may see and get copies of this information.

We might use or share information about you for:

Treatment. Such as when our physicians and nurses discuss your care.

Payment. Such as when we bill your insurance company for services provided to you.

Operations. Such as when we work to make the quality of the care we provide better. When we give out information about the different services we provide. Or when we contact community residents to ask for donations.

Other ways. Such as when we send disease reports to county and state health officials (this is required by law). When we provide information to funeral directors, organ donation groups and researchers. When we share information to protect the health and safety of others or you. Or when we respond to court requests. We also may send you appointment reminders, greeting cards and newsletters.

How you may see and get copies of this information
You have the right to:

• Ask for restrictions on the ways we use and give out your information. However, we are not required to do what you ask.
• Get and inspect a copy of your health record.
• Add information to your health record.
• Ask that your health information be sent to an alternate address or that you be called at an alternate phone number.
• Change your mind if you told us we could use or share your information for reasons other than those listed above.
• Get a list of the times we gave out your information. It will be a list of the times that the law requires us to keep a record of giving out your information.

Our Commitment to Respect Privacy
Mercy Medical Center - Clinton is required to:

• Keep your information private.
• Let you know if we cannot do what you have asked us to do with your information.
• Try to reach you at another location or phone number, if you ask us to do so.
• Use and / or give out your information as listed above and as the law permits, unless we have your permission to do more.

As we serve our patients, we at Mercy Medical Center - Clinton may change what we do with your information. If we make a change, we will post the new notice in the admitting areas of our health system. You may call or write to us to check if we have made any changes. A copy of our updated Notice will be provided to you upon your request.

Complaints
If you believe your privacy rights have been violated, you may voice your complaints to Mercy Medical Center – Clinton at the address or phone number below. You also may complain to the Department of Health and Human Services. You will not be mistreated for filing a complaint.

Contact Information
Mercy Medical Center - Clinton
Attn: Privacy Officer
1410 North 4th Street
Clinton, IA 52732
Phone: 563-244-3861
E-mail: CLPrivacyOfficer@mercyhealth.com