Privacy

Privacy Statement

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact the Compliance Officer at 812-663-1375
or write in care of Decatur County Memorial Hospital,
720 North Lincoln Street, Greensburg, Indiana 47240
WHO WILL FOLLOW THIS NOTICE
This notice describes our hospital’s practices and that of:
• Any health care professional authorized to enter information into your hospital chart.
•  All departments and units of the hospital.
• Any member of a volunteer group we allow to help you while you are in the hospital.
•  All employees, staff and other hospital personnel.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to
protecting medical information about you. We create a record of the care and services you receive
at the hospital. We need this record to provide you with quality care and to comply with certain
legal requirements. This notice applies to all of the records of your care generated by the
hospital, whether made by hospital personnel 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.

This notice will tell you about the ways in which we may use and disclose medical information about
you.  This notice will also describe your rights, and certain obligations we
have, regarding the use and disclosure of medical information.

WE ARE REQUIRED BY LAW
•  To make sure that medical information which identifies you is kept private, and in the event of
a breach of your personal health information (PHI) you will be notified.
• To give you this notice of our legal duties and privacy practices with respect to medical
information about you.
•    To follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For
each category of uses or disclosures we will explain what we mean and try to give some examples.
Not every use or disclosure in a category will be listed. However, all of the ways we are permitted
to use and disclose information will fall within one of the categories.

   For Treatment.  We may use medical information about you to provide you with medical 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 the hospital. For
example, a doctor treating you for a broken leg may need to know if you have diabetes because
diabetes may slow the healing process.  In addition, the doctor may need to tell the dietitian if
you have diabetes so that we can arrange for appropriate meals.
Different departments of the hospital also may share medical information about you in order to
coordinate the different services you need, such as prescriptions, lab work and x-rays. We also may
disclose medical information about you to people outside the hospital who may be involved in your
medical care after you leave the hospital, such as family members, clergy or others we may use to
provide services that are part of your care.
 For Payment. We may use and disclose medical information about you so that the treatment and
services you receive at the hospital may be billed to and payment may be collected from you, an
insurance company or a third party. For example, we may need to give your health plan information
about surgery you received at the hospital so your health plan will pay us or reimburse you for the
surgery. We may also tell your health plan about a treatment you are going to receive to obtain
prior approval or to determine whether your plan will cover the treatment.
 For Health Care Operations. We may use and disclose medical information about you for hospital
operations. These uses and disclosures are necessary to run the hospital and make sure that all of
our patients receive quality care. For example, we may use medical information to review our
treatment and services and to evaluate the performance of our staff in caring for you. We may also
combine medical information about many hospital patients to decide what additional services the
hospital should offer, what services are not needed, and whether certain new treatments are
effective.  We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care
and services we offer. We may remove information that identifies you from this set of medical
information so others may use it to study health care and health care delivery without learning who
the specific patients are.
 Treatment Alternatives. We may use and disclose medical information to tell you about or
recommend possible treatment options or alternatives that may be of interest to you.
 Health-Related Benefits and Services. We may use and disclose medical information to tell you
about health-related benefits or services that may be of interest to you.
 Fundraising Activities. We may use medical information about you to contact you in an effort to
raise money for the hospital and its operations. We may disclose medical information, to the
foundation related to the hospital, so the foundation may contact you about raising money for the
hospital. We will only release your demographic information, health insurance status, dates you
received care, the hospital department where you received service, the treating physician and your
outcome information. You may choose to opt out of any or all hospital fundraising efforts and your
decision will have no impact on your treatment or payment of services.
TO OPT OUT OF SPECIFIC OR ALL HOSPITAL FUNDRAISING
EFFORTS,  you must contact the Foundation Office in writing at 720 N. Lincoln Street Greensburg, IN
47240 or by email: foundation@dcmh.net
 Hospital Directory. We may include certain limited information about you in the hospital
directory while you are a patient at the hospital. This information may include your name, location
in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation.
The directory information, except for your religious affiliation, may also be released to people
who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as
a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and
clergy can visit you in the hospital and generally know how you are doing.
 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. We may also give
information to someone who helps pay for your care. We may also tell your family or friends your
condition and that you are in the hospital.  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.
 Research. Under certain circumstances, we may use and disclose medical information about you for
research purposes. For example, a research project may involve comparing the health and recovery of
all patients who received one medication to those who received another, for the same condition. All
research projects, however, are subject to a special approval process. This process evaluates a
proposed research project and its use of medical information, trying to balance the research needs
with patients’ need for privacy of their medical information. Before we use or disclose medical
information for research, the project will have been approved through this research approval
process, but we may, however, disclose medical information about you to people preparing to conduct
a research project, for example, to help them look for patients with specific medical needs, so
long as the medical information they review does not leave the hospital. We will almost always ask
for your specific permission if the researcher will have access to your name, address or other
information that reveals who you are, or will be involved in your care at the hospital.
 As Required By Law. We will disclose medical information about you when required to do so by
federal, state or local law.
 To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about
you when necessary to prevent a serious threat to your health and safety or the health and safety
of the public or another person. Any disclosure, however, would only be to someone able to help
prevent the threat.
SPECIAL SITUATIONS

 Organ and Tissue Donation. If you are an organ donor, we may release medical information to
organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ
donation bank, as necessary to facilitate organ or tissue donation and transplantation.
 Military and Veterans. If you are a member of the armed forces, we may release medical
information about you as required by military command authorities. We may also release medical
information about foreign military personnel to the appropriate foreign military authority.
 Workers’ Compensation. We may release medical information about you for workers’ compensation or
similar programs. These programs provide benefits for work-related injuries or illness.
 Public Health Risks. We may disclose medical information about you for public health activities.
These activities generally include the following:

•    to prevent or control disease, injury or disability;
•  to report births and deaths;
•  to report child abuse or neglect;
•    to report reactions to medications or problems with products;
•    to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the victim of
abuse, neglect or domestic violence. We will only make this disclosure if you agree or when
required or authorized by law.
 Health Oversight Activities. We may disclose medical information to a health oversight agency for
activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for the government to
monitor the health care system, government programs, and compliance with civil rights laws.
 Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical
information about you in response to a court or administrative order. We may also disclose medical
information about you in response to a subpoena, discovery request, or other lawful process by
someone else involved in the dispute, but only if efforts have been made to tell you about the
request or to obtain an order protecting the information requested.
 Law Enforcement. We may release medical information if asked to do so by a law enforcement
official:
•    In response to a court order, subpoena, warrant, summons or similar process;
•    To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the
person’s agreement;
•    About a death we believe may be the result of criminal conduct;
•  About criminal conduct at the hospital; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the
identity, description or location of the person who committed the crime.
 Coroners, Medical Examiners and Funeral Directors. We may release medical information to a
coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.
 National Security and Intelligence Activities. We may release medical information about you to
authorized federal officials for intelligence, counterintelligence, and other national security
activities authorized by law.
   Protective Services for the President and Others.  We may disclose medical information about
you to authorized federal officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special investigations.
 Inmates.  If you are an inmate of a correctional institution or under the custody of a law
enforcement official, there may be circumstances where we may release medical information about you
to the correctional institution or law enforcement official. This release would be necessary (1)
for the institution to provide you with health care; (2) to protect your health and safety or the
health and safety of others; or (3) for the safety and security of the correctional institution.
Otherwise, under normal circumstances, inmates will authorize the release of their medical
information.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical information we maintain about you:
 Right to Inspect and Copy. You have the right to inspect and request a copy of medical
information that may be used to make decisions about your care.
Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect or request a copy of medical information that may be used to make decisions about you,
you must submit your request in writing to the Health Information Management office. If you request
a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies
associated with your request.
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. Another licensed
health care professional chosen by the hospital will review your request and the denial. The person
conducting the review will not be the person who denied your request. We will comply with the
outcome of the review.
 Right to Amend. If you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information.  You have the

right to request an amendment for as long as the information is kept by or for the hospital.
To request an amendment, your request must be made in writing and submitted to the Director of
Health Information Management. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to
support the request. In addition, we may deny your request if you ask us to amend information that:
• Was not created by us, unless the person or entity that created the information is no longer
available to make the amendment;
•       Is not part of the medical information kept by or for the hospital;
• Is not part of the information which you would be permitted to inspect and copy; or
•     Is accurate and complete.
 Right to an Accounting of Disclosures. You will receive a notification of breaches of your
unsecured PHI. You have the right to request an “accounting of disclosures.” This is a list of the
disclosures we made of medical information about you.
To request this list of accounting of disclosures, you must submit your request in writing to the
Director of Health Information Management. Your request must state a time period, which may not be
longer than six years and may not include dates before February 26, 2003. Your request should
indicate in what form you want the list (for example, on paper, electronically). The first list you
request, within a 12 month period, will be free. For additional lists, we may charge you for the
costs of providing the list. We will notify you of the cost involved and you may choose to withdraw
or modify your request at that time before any costs are incurred.
 Right to Request Restrictions. You have the right to request a restriction or limitation on the
medical information we use or disclose about you for treatment, payment or health care operations,
unless required by law. 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 the payment for your care, like a
family member or friend. For example, you could ask that we not use or disclose information about a
surgery you had. 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.

To request restrictions, you must make your request in writing to the Director of Health
Information Management. In your request, you must tell us (1) what information you want to limit;
(2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to
apply, for example, disclosures to your spouse.
You may request a restriction of your PHI to your health plan. The restriction must be for purposes
other than treatment and the service must be paid in full (other than by the health plan). If
multiple services are billed together (bundled service), a portion of the services may not be able
to be restricted. For more information contact the Director of Health Information Management. We
may include previously restricted PHI, when billing health plans for follow-up treatment. This may
be needed to support the medical necessity of follow-up care and you have not requested a
restriction or paid out pocket for the follow-up care.
 Right to Request Confidential Communications. You have the right to request that we communicate
with you about medical matters in a certain way or at a certain location. For example, you can ask
that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to Decatur County
Memorial Hospital, Attn: Compliance Officer, 720 North Lincoln Street, Greensburg, IN 47240. We
will not ask you the reason for your request. We will accommodate all reasonable requests. Your
request must specify how or where you wish to be contacted.
 Right to a 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.
You may obtain a copy of this notice at our website, www.dcmh.net. To obtain a paper copy of this
notice, ask the admitting clerk.

CHANGES TO THIS NOTICE
 We reserve the right to change this notice. We reserve the right to make the revised or changed
notice effective for medical information we already have about you as well as any information we
receive in the future. We will post a copy of the current notice in the hospital. The notice will
contain on the first page, in the top right-hand corner, the effective date. In addition, each time
you register at or are admitted to the hospital for treatment or health care services as an
inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with
the hospital or with the Secretary of the Department of Health and Human Services. To file a
complaint with the hospital, contact the Corporate Compliance Officer, Decatur County Memorial
Hospital, 720 North Lincoln Street, Greensburg, Indiana 47240.   Phone 812-663-1375, e-mail:
brad.green@dcmh.net
You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply
to us will be made only with your written permission.  If you provide us permission to use or
disclose medical information about you, you may revoke that permission, in writing, at any time. If
you revoke your permission, we will no longer use or disclose medical information about you for the
reasons covered by your written authorization.   You understand that we are unable to take back any
disclosures we have already made with your permission, and that we are
required to retain our records of the care that we provided to you.