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Notice of Privacy Practices

Notice of Privacy Practice Effective 9/9/13 Memorial Hospital, Chester, Illinois 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.

Versión española de la transferencia directa de las prácticas de la aislamiento

This notice describes Memorial Hospital's practices and that of:

  • Healthcare professionals authorized to enter information into your hospital chart.

  • Departments and units of the hospital.

  • Members of volunteer groups.

  • Employee staff and other hospital personnel.

We understand that medical information about you/your health is personal. We are committed to protecting your medical information. 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(s). Your doctor(s) may have different policies or notices regarding the doctor's use/disclosure of your medical information created in the doctor's office/clinic. If you have any further questions about this Notice, you may contact the Privacy Officer at 6l8-826-458l Ext. 2345. We will notify you in writing when a breach in your medical information occurs. We 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 that identifies you is kept private;

  • give you this notice of our legal duties and privacy practices with respect to medical information about you; and

  • follow the terms of the notice that is currently in effect.

The following categories describe different ways that we use/disclose medical information. For each category of uses/disclosures we will explain what we mean and give examples. Not every use/disclosure in a category will be listed. All of the ways we are permitted to use/disclose information will fall within one of the categories.

FOR TREATMENT. May use medical information about you to provide medical treatment or services. We may disclose medical information about you to doctors/nurses/technicians/ other hospital personnel who are involved in taking care of you. Example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow healing process. In addition, the doctor may need to tell the dietitian if you have diabetes to arrange for appropriate meals. Various departments of the hospital also may share medical information in order to coordinate different things you need, such as prescriptions/lab data/x-rays. We also may disclose medical information about you to other entities who are involved in your medical care, such as family members, clergy or others who provide services that are part of your care, ie. your family physician, specialist, medical students, nursing home, home health agency, Randolph County Health Department or other hospital associates.

FOR PAYMENT. We may use/disclose medical information about you so that treatment and services you receive at Memorial may be billed to and payment collected from you, all insurance companies or a third party. Example, we may need to give your health plan, information about surgery you received 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. We may provide your protected health information (PHI) to our business associates, such as billing or claims processing companies.

FOR HEALTH CARE OPERATIONS. Disclosure of health information about you may be necessary for hospital operations in order to run the hospital and make sure that patients receive quality care. Example, May use medical information to review treatment/services and evaluate performance of our staff in your care. May combine medical information we have with many hospital patients to decide what additional services should be offered, what services are not needed, and whether new treatments are effective. May also disclose information to doctors, nurses, technicians and other hospital personnel for review and learning purposes. May combine medical information we have with medical information from other hospitals to compare where to improve. May remove information that identifies you from the PHI so others may use it to study healthcare delivery without specific identification. May provide your PHI to our accountants/attorneys/consultants/accreditation bodies to assure compliance. If this facility sells/transfers assets to or consolidates/ merges with an entity who is or will be a covered entity at completion of the transaction) or use/disclose PHI in connection with such transaction, Due Diligence will be utilized in transferring records containing PHI. Uses/disclosures that are incidental to otherwise permitted use/disclosure may occur, however, such are not considered a violation of the Rule provided that the covered entity has met reasonable safeguards and minimum necessary requirements. Example: Doctors can talk to patients in semi-private rooms and can confer at nurse's stations without fear of violating the Rule if overheard by a passerby.


  1. Appointment Reminders,

  2. Follow-up Phone Calls, Post Discharge,

  3. Treatment Alternatives.

  4. Health-Related Benefits and Services.

FUNDRAISING ACTIVITIES May use your PHI in an effort to raise money for the hospital. We may disclose PHI to a foundation that is raising money for the hospital. Permissible fundraising activities include appeals for money, sponsorship of events, etc. They do not include royalties or remittances for the sale of products of third parties (except auctions, rummages sales, etc.) You have the option to opt out of receiving such communications.

MARKETING Must obtain an individual's written authorization to use PHI for marketing purposes. Exception Doctors/other covered entities communicating with patients about treatment options are not considered marketing. You have the option to opt out of receiving such communications.

UNDERWRITING PURPOSES Memorial is not permitted to disclose genetic information for underwriting purposes. This means we will not disclose genetic information to a health plan that could disqualify you from benefits.

HOSPITAL DIRECTORY May include certain limited information about you in the hospital directory while you are a patient. Information may include name, location in the hospital, your general condition (ie. fair/stable) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Religious affiliation may be given to a member of the clergy even if they don't ask for you by name.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. May release PHI about you to a friend/family member who is involved in your care. In addition, may disclose PHI about you to your family doctor, power of attorney for healthcare, or an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

FOR RESEARCH PURPOSES In certain circumstances, may provide PHI in order to conduct medical research.

AS REQUIRED BY LAW Will disclose PHI about you when required to do so by Law.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY May use/disclose PHI about you when necessary to prevent a serious threat to health/safety to you or the public. Any disclosure would only be to someone able to help prevent the threat. May disclose PHI to a person subject to jurisdiction of the FDA for public health purposes related to the quality/safety/effectiveness of FDA-regulated products/ activities such as collecting/reporting adverse events/dangerous products or defects/problems with FDA-regulated products.


ORGAN/TISSUE DONATIONS. May release PHI required by Law to organizations that handle organ/eye/tissue donation bank, procurement, and/or transplantation.

WORKERS' COMPENSATION. May release PHI for workers' compensation or similar programs that provide benefits for work-related injury/illness.

PUBLIC HEALTH RISKS. May disclose PHI for public health activities. These activities
generally include the following:

  • to prevent or control disease/injury/disability;

  • to report births/deaths/child or adult abuse/neglect, medication reactions or problems with products;

  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading disease;

  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence when required by Law.

HEALTH OVERSIGHT ACTVITIES. May disclose PHI to a health oversight agency for activities authorized by law. This may include audits/investigations/inspections/licensure. Such activities are necessary for the government to monitor health care systems/government programs/compliance with civil rights laws.

LAWSUITS AND DISPUTES. If you are involved in a lawsuit/dispute, we may disclose PHI about you in response to a court or administrative order, ie. subpoena, discovery requestor other lawful process by someone else involved.

INMATES. If an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI to them. 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;
(3) for the safety and security of the correctional institution or
(4) for payment of bills.

LAW ENFORCEMENT. May release PHI if asked to do so by a law enforcement official:

  • Response to a court order, subpoena, warrant, summons or similar process;

  • Identify/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, location of the crime or the identity/ description/location of the person who committed the crime.

MILITARY AND VETERANS. If you are a member of the armed forces, we may release PHI as required by military command authorities. May release medical information about foreign military personnel to foreign military authority.

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS. May release PHI to a coroner/medical examiner. This may be necessary to identify a deceased person or determine the cause of death. May release PHI about patients in the hospital to funeral directors as necessary to carry out their duties.

NATIONAL SECURITY/INTELLIGENCE ACTIVITIES. May release PHI to authorized Federal officials for intelligence, counterintelligence, and other National security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT & OTHERS. May disclose PHI to authorized Federal officials so they may provide protection to the President/other authorized persons/foreign heads of state or to conduct special investigation.


RIGHT TO INSPECT/COPY. You have the right to inspect and copy PHI that may be used to make decisions about your care. This includes medical and billing records, but does not include psychotherapy notes. Instead of providing the PHI, we may provide you with a summary or explanation of the PHI as long as you agree.

To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to the Health Information Management Department. If you request a copy of the information, we may charge a fee for costs. We will respond within 30 days of receiving your request. We may deny your request to inspect/copy in certain limited circumstances. If denied access to PHI, you may request that the denial be reviewed. We will respond to the denial request within 30 days after receiving your written request for review. In certain situations we may AGAIN deny that request. If we do deny, we will tell you in writing our reasons for the denial.


RIGHT TO AMEND. If you feel the PHI we have about you is incorrect/incomplete, you may ask 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 on a specific form for such purpose and you must provide a reason that supports your request. The request must be made to the Privacy Officer. (6l8-826-4581 Ext. 2345).

We may deny your request for an amendment if it is not in writing or does not include areas on to support the request. We must act upon your request within 60 days unless a one-time extension of 30 days is agreed upon and give reason for the delay.

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 PHI kept by or for the hospital;

  • The information wanting changed has nothing to do with the current admission to this healthcare organization.

  • Is accurate and complete.

We will give you a written denial which includes the reason for the denial. This denial will include information as to how to complain to your organization or the Secretary of Health and Human Services. You may file a "Statement of Disagreement" of the denial giving the basis for the disagreement. A written statement must be made on a standard form provided by the hospital and must be limited to one page. This facility may give the patient a written rebuttal to the "Statement of Disagreement".

The facility must link or append certain amendment request information to the patient's record, ie. Request for Amendment, Hospital Denial, Patient's Statement of Disagreement and Hospital's Rebuttal (if any). If the patient does not submit a written statement of disagreement, the hospital, upon request of the patient, must include certain amendment request information with any future disclosures of PHI of issue. If a Standard Transaction does not allow you to include the required additional information when disclosing PHI, the hospital may transmit the additional information to the recipient separately.

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 make this specific request, you must submit a written request to the Hospital Privacy Officer. Memorial may approve or deny the request depending upon the circumstances.

RIGHT TO GET A LIST OF THE DISCLOSURES WE HAVE MADE List will not include uses/disclosures for treatment/payment/health care operations listed in this Privacy Notice. The list we will give you will include disclosures made in the last six years after the effective date of his HIPAA Compliance Requirement, unless you request a shorter time after the effective date of April 14, 2003. The list will include date of the disclosure, to whom PHI was disclosed (including their address, if known), description of the information disclosed and reason for the disclosure. Within 30 days of request, one list will be provided at no charge, for more requests in same year, a $5.00 charge will be made for each request.

RIGHT TO REQUEST RESTRICTIONS You have the right to request a restriction/limitation of the PHI we use/disclose about you for treatment/payment/ healthcare operations. We cannot refuse to restrict disclosure of information about a surgery you had performed if you are going to pay in full prior to your services. We are not required to agree to your request and may not comply unless there are unusual circumstances. Prior to making the restriction, the Privacy Officer will review the request. If we do agree with your restriction, we will comply unless the information is needed to provide you emergency

To request restrictions, request must be in writing to the Privacy Officer. In your request, you must tell:

  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.

RIGHT TO A PAPER COPY OF THIS NOTICE You have the right to a paper copy of this notice. May also obtain a copy of this notice at our website, A paper copy of this notice may be obtained from the clerk at the Registration Desk.

CHANGES TO THIS NOTICE We reserve the right to change this notice at any time and may make the revised notice effective for PHI we already have about you as well as any PHI we receive in the future. A copy of the current notice is posted with the effective date. Also, each time you register at the hospital for treatment, you will be offered or given a copy of the current notice in effect.

GRIEVANCES If you believe your privacy rights have been violated, you may file a written grievance with the hospital Privacy Officer, 6l8-826-4581, ext. 2345 or Secretary of the Department of Health/Human Services, 877-696-6775. There will be no retaliation against a person who exercises privacy rights or files a grievance against the hospital.

EXCLUSIONS FOR EMPLOYMENT RECORDS Employment records maintained by this hospital in its capacity as an employer are excluded from the definition of PHI. However, individually identifiable health information created, received or maintained by this facility in its health care capacity is protected health information.

OTHER USES OF MEDICAL INFORMATION Other uses/disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written permission. Some information requires a special authorization such as use of psychotherapy notes, marketing or fundraising use or disclosure that constitute a sale of PHI. If you provide us permission to use/disclose PHI, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use/disclose PHI 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.

In special cases in which the minor controls his/her own health information under Illinois State Law, and that Law does not define the parents' ability to access the child's health information, a licensed health care provider continues to be able to exercise discretion to grant or deny such access.

LIMITED DATA SET A limited data set may be created and disseminated (that does not include directly identifiable information) for research, public health and health care operations. The recipient must agree to limit the use of the data set for the purposes for which it was given and to ensure the security of the data, as well as not to identify the information or use it to contact any individual.

Revised: 1/28/02; l/30/02; 4/5/02; 5/21/02; 8/13/02; 8/30/02; 9/02/02; 2/10/02; 1/21/03
10-14-10, 8/22/13.
Reviewed: 8/1/11, 11/1/12.

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