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.
This notice describes the privacy practices of Memorial Hospital and those who provide
services to patients at this hospital. (Hereafter referred to as we.)
Patient Health Information
Under federal law, your patient health information is protected and confidential. Patient health
information includes information about your symptoms, test results, diagnosis, treatment and
related medical information. Your health information also includes payment, billing and insurance
How We Use Your Patient Health Information
We use health information about you for treatment, to obtain payment, and for our health care
operations, including administrative purposes and evaluation of the quality of care that you
receive. Under some circumstances, we may be required to use or disclose the information even
without your authorization.
Selected Examples of Treatment, Payment, and Health Care Operations
Treatment: We will use and disclose your health information to provide you with medical treatment
or services. For example nurses, physicians, and other members of your treatment team
will record information in your record and use it to determine the most appropriate course of
care. We may also disclose the information to other health care providers who are participating
in your treatment, to pharmacists who are filling your prescriptions, and to family members who
are helping with your care. We may also disclose information to someone who helps pay for
We will use and disclose your health information for payment purposes. For example,
we may need to obtain authorization from your insurance company before providing
certain types of treatment. We will submit bills and maintain records of payments from your
health plan or to a friend or family member involved in or responsible for payment of your
Health Care Operations:
Other Uses and Disclosures
We will use and disclose your health information to conduct our standard
internal operations including, but not limited to, proper administration of records, evaluation
of the quality of treatment, and to assess the care and outcomes of your case and others like
We may use or disclose identifiable health information about you for other reasons, even without
your written authorization.. Subject to certain requirements, we are permitted to give out health
information without your written authorization for the following purposes:
Required by Law: We may be required by law to report gunshot wounds, suspected abuse or
neglect, or similar injuries and events.
Public Health Activities: As required by law, we may disclose vital statistics, diseases, information
related to recalls of dangerous products, and similar information to public health
Health Oversight: We may be required to disclose information to assist in investigations and
audits, eligibility for government programs, and similar activities.
Judicial and Administrative Proceedings: We may disclose information in response to an
appropriate subpoena, court order or search warrant.
Law Enforcement Proceedings: Subject to certain restrictions, we may disclose information
required by law enforcement officials.
Deaths: We may report information regarding deaths to coroners, medical donation agencies,
examiners, funeral directors and organ donation agencies.
Serious Threat to Health or Safety: We may use and disclose information when necessary to
prevent a serious threat to your health and safety or the health and safety of the public or
Military and Special Government Functions: If you are a member of the armed forces, we
may release information as required by military command authorities. We may also disclose
information to correctional institutions or for national security purposes.
Research: We may use or disclose information for approved medical research.
Worker’s Compensation: We may release information about you for worker’s compensation
or similar programs providing benefits for work-related injuries or illnesses.
If you are an inpatient at Memorial Hospital we may ask you for your permission to disclose
limited information about you to clergy or include it in the Hospital Patient Directory. The
information included would be your name, location in the hospital and religious affiliation. You
may choose to limit part or all the information or choose not to be included in the clergy listing
or Hospital Patient Directory. We may also tell family or friends your general condition and that
you are a patient at Memorial Hospital if they inquire.
Under limited circumstances, we may disclose information to notify or locate your relatives or
to assist disaster relief agencies.
In any other situation, we will ask for your written authorization before using or disclosing any
identifiable health information about you. If you choose to sign an authorization, you can later
revoke that authorization to stop any future uses and disclosures.
You have the following rights with regard to your health information. Please contact the Contact
Person listed to obtain the appropriate forms for exercising these rights.
Request Restrictions: You may request restrictions on certain uses and disclosures of your health
information. We are not required to agree with such restrictions, but if we do agree, we must
abide by those restrictions.
Confidential Communications: You may ask us to communicate with you confidentially by, for
example, sending notices to a special address or not using postcards to remind you of appointments.
Inspect and Obtain Copies: In most cases, you have the right to look at or get a copy of your
health information. There may be a charge for the copies.
Amend Information: If you believe that information in your record is incorrect, or if important
information is missing, you have the right to request that we correct/amend the existing information
or add the missing information.
Accounting of Disclosures: You may request a list of instances where we have disclosed health
information about you for reasons other than treatment, payment or health care operations or for
which you have signed an authorization.
Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide
this Notice about our legal duties and privacy practices regarding protected health information,
and to abide by the terms of the notice currently in effect.
We may use your information to contact you with appointment reminders. We may also contact
you to provide information about treatment alternatives or other health-related benefits and
services that may be of interest to you.
Changes in Privacy Practices
We may change our policies at any time and post the new Notice in the
Admissions/Registration area and on our website. All changes in the notice will be effective for
all personal health information we maintain even that collected under prior policies. You can
also request a copy of our Notice at any time. For more information about our privacy practices,
contact the Contact Person listed below.
If you are concerned that we have violated your privacy rights, or if you disagree with a decision
we made about your records, you may contact the person listed below. You also may send a
written complaint to the U.S. Department of Health and Human Services and/or the Contact
Person listed below. You will not be penalized in any way for filing a complaint.
If you have any questions, requests, or complaints, please contact:
Jill Vough, Privacy Officer
91 Hospital Drive
Towanda, PA 18848
Memorial Hospital and those who provide services to patients at Memorial Hospital are independent
contractors and do not assume any liability for the services or conduct of each other.
Effective Date: The effective date of this Notice is: April 14, 2003.
Date Approved: March 19, 2003
Approved by HIPAA Committee 03/19/03